Every finding on record at Autumn Lake Healthcare at Madison

Based on observation, and facility policy reviewed for the initial tour of the kitchen, the facility failed ensure thawing of meat per the requirement. The findings include:Observation on 8/15/2025 at 9:38 AM, identified fish being thawed on one side of a double sink in a water bath and chicken patties in the other side of the double sink in a plastic package without any running water being used. Interview with the Food Service Manager on 8/19/2025 at 11:32 AM identified the fish was in a water bath on 8/15/2025 and he drained the water with the fish in it. The Food Service Manager further indicated that the facility policy for thawing frozen food was to thaw the items either in the refrigerator or under cold running water. Occasionally they thaw frozen food in the microwave. He could not determine why the cook had the fish in a water bath rather than under cold running water, or why the chicken patties in the sink were being thawed without the benefit of running water. Review of the Food Storage Cold policy dated May 2014 directed, in part, the cook thaws frozen items requiring defrosting, before preparation, under refrigeration, in the microwave for immediate use, or in a sealed container immersed in cold running water.

Based on observations, facility documentation, interviews and policy review for 2 of 2 samples residents (Resident #33 and Resident #58) reviewed for choices, the facility failed to honor the residents right to make choices within the facility. The findings included:1. Resident #33's diagnoses included malignant neoplasm of the frontal lobe, atherosclerosis of bilateral extremities, and apraxia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and was dependent on staff for personal hygiene, oral hygiene, and dressing. The Resident Care Plan dated 7/6/25 identified Resident #33 was at risk for a communication problem related to unclear speech. Interventions included anticipating and meeting the resident's needs as well as avoiding isolation. Interview with the Responsible Party, Person #1, on 8/19/25 at 2:15 PM identified that Resident #33 had presented with long, greasy hair during the last couple of medical appointments. Additionally, Person #1 identified the request for a haircut was brought up to social services and nursing staff multiple times throughout the last couple of months, as well as a form for receiving a haircut had been filled out in the business office, but Resident #33 still had not received a haircut. Observations between 8/19/25 and 8/25/25 identified Resident #33 with slicked back hair extending about 3 inches below the nape of his/her neck. Interview with Resident #33 on 8/20/25 at 1:29 PM identified he/she did not like their current hair length and preferred it short. Interview with the Administrator on 8/20/25 at 1:58 PM identified there was a family meeting held on 8/5/25 with Resident #33's Person #1 to address care concerns, including a haircut. Additionally, she identified that the requests for a haircut were not honored because she did not think the hairdresser would be comfortable cutting his/her hair due to Resident #33's neck positioning (leaning to one side), adding that the nursing assistants or hospice could provide him/her with a haircut. The Administrator failed to indicate why a haircut had not been provided to Resident #33 since Person #1 requested the haircut for several months or since the meeting on 8/5/25 (15 days). Interview with the Hairdresser on 8/20/25 at 2:14 PM identified she was notified by written request when a resident asked to have a haircut. She indicated that she kept all her request forms, could not recall that Resident #33 had ever submitted a request for his/her hair to be cut, and was unable to find a request among her stored records. Interview with the Business Office Manager on 8/20/25 at 4:34 PM identified Resident #33's responsible party submitted a haircut request, which was passed on to the hairdresser. The Business Office Manager could not recall when the haircut request had been written, could not provide a copy of the haircut request, and stated the next time the hairdresser came to the facility, Resident #33 would receive a haircut. 2. Resident #58's diagnoses included a fracture of the right femur, anxiety, and parkinsonism. The admission Nursing assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 12 but the assessment was incomplete (as 2 questions were not addressed). Resident #58 was independent with eating, required moderate assistance with chair/bed-to-chair transfers, and extensive assistance with locomotion. The Resident Care Plan (RCP) dated 8/5/2025 identified Resident #58 had a potential nutritional risk due to medical comorbidities. Interventions included providing/serving the diet as ordered, monitor intake and record every meal, offer replacement foods as necessary, and the registered dietician would evaluate and make diet change recommendations as needed. Review of a physician's order dated 8/5/2025 identified Resident #58 was on a regular texture, regular consistency diet. Review of the dietician Nutritional Evaluation dated 8/6/2025 identified Resident #58 had allergies to food dyes but failed to note any further intolerance or problems. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, required maximal assistance for chair/bed-to-chair transfers, was dependent for personal hygiene, and required supervision for eating. Interview with Resident #58's family member, Person #7, on 8/15/2025 at 12:41 PM identified that caffeinated coffee made the resident violently ill. Person #7 indicated that he/she had requested decaffeinated (decaf) coffee, and tea, but staff, on multiple occasions, were unable to convey if the coffee being served was regular or decaf, so Resident #58 could not consume any coffee during meals. Interview and observation on 8/15/2025 at 12:37 PM with Person #7 identified that Resident #58 had just been served an unknown type of coffee with his/her meal, he/she questioned NA #4 whether the coffee was regular or decaf, but NA #4 was unable to indicate which type of coffee was served. Further, Person #7 stated Resident #58 had been upset because he/she enjoyed decaf coffee and was unable to drink any coffee served due to the fear of becoming violently ill. Interview with Nurse Aide (NA) #4 on 8/15/2025 at 12:39 PM identified she was unaware of the type of coffee, regular or decaf, contained in the carafe she used, was unaware that Person #7 had questioned her as to the type of coffee served, and she had never been told by anyone what coffee type she distributed to residents. Additionally, NA #4 indicated that the beverage cart was presented from the Dietary Department without any other coffee choices and lacked a decaf coffee option. Interview with the Dietary Director on 8/15/2025 at 12:57 PM identified that all residents were served regular coffee from the carafe, but that instant coffee was available in a packet as a decaf option but never served in a carafe. Interview and review of Resident #58's self-selected menu options with the Dietary Director on 8/25/2025 at 12:33 PM for menus dated 8/5/2025 through 8/20/2025 identified that the resident had requested tea to be served with meals as his/her beverage of choice. Review of Resident #58's printed meal tickets, used to indicate preferences during meal distribution, failed to identify his/her request for tea and directed to provide either tea or coffee. The Dietary Director stated beverages were served from the beverage cart by nursing aides (NA)/servers and that both options of coffee and tea were always printed on Resident #58's ticket. The Dietary Director was unable to explain how a NA/server would be able to identify Resident #58's choice of tea if the request was not printed on the meal ticket. The Dietary Director stated he did not provide decaf coffee packets on the beverage cart that was sent to Resident #58's unit. Further, he was unaware that Resident #58 could not drink caffeinated coffee due to becoming ill, or that Resident #58 had requested decaf coffee. The Dietary Director indicated that going forward, Resident #58's ticket would be printed to indicate decaf under beverage to be served. The facility's Standardized menus policy identified in part, that the facility will support the resident's right to make personal dietary choices, and if during meal observations a resident's dietary intake appears inadequate, the facility will make reasonable efforts to review and/or adjust the menu and/or the resident's food plan to meet the nutritional, religious, cultural, ethnic needs, and preferences of the resident. Review of the Resident Rights Policy dated 7/21 directed in part that residents have the right to self-determination and a dignified existence.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #30 and Resident #33) reviewed for choices, the facility failed to follow their grievance policy. The findings include:1. Resident #30's diagnosis included multiple sclerosis, anxiety, and pain. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment and required partial to moderate assistance with upper body dressing and was dependent for lower body dressing. The Resident Care Plan dated 5/7/2025 identified a problem with self-care for Activities of Daily Living (ADLs). Interventions included providing extensive assistance with bathing, dressing, and bed mobility. Interview with Resident #30 on 8/15/2025 at 10:30 AM identified missing pants. Resident #30 indicated that he/she had informed the laundry personnel but had not received any response. Review of Resident #30's nurse's notes and the grievance log for July and August 2025 failed to identify Resident #30 had any missing items. Interview with Social Worker (SW) #1 on 8/20/2025 at 9:04 AM identified she was never informed that Resident #30 had a missing item. Interview with Registered Nurse (RN) #1 on 8/20/25 at 9:21 AM identified that she was never informed of Resident #30's missing pants. Interview with Laundry Aide #2 on 8/20/2025 at 9:50 AM identified that she was aware of Resident #30's missing pants, had attempted to find the missing item but was unable, and had informed her previous District Director of Laundry and Housekeeping of the lost pants. Interview with the District Director of Laundry and Housekeeping on 8/20/2025 at 9:50 AM identified that he had only been with the facility for a week and had no knowledge of Resident #30's missing pants. Interview with the Administrator on 8/20/2025 at 11:50 AM identified that subsequent to surveyor inquiry, her staff had notified her of the missing item on 8/20/2025 and she was currently completing a grievance form. The Administrator indicated that anyone in the facility would have been able to fill out a grievance form and that if the laundry aides were not comfortable filling out the form, they should have escalated the missing item information to a manager to complete. 2. Resident #33's diagnoses included malignant neoplasm of the frontal lobe (brain), atherosclerosis of bilateral extremities, and apraxia (a brain motor disorder). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and was dependent on staff for personal hygiene, oral hygiene, and dressing. The Resident Care Plan dated 7/6/25 identified Resident #33 was at risk for a communication problem related to unclear speech at times. Interventions included anticipating and meeting needs as well as avoiding isolation. A Social Service note dated 8/5/25 at 11:40 PM identified a meeting was held with Resident #33's responsible party, social worker, Business Office Manager, Director of Nursing Services, and Administrator. Family concerns were addressed, and support was available. The facility was to follow up with the psychiatrist and doctor, and a second meeting would occur with updates. Interview with the Responsible Party, Person #1 on 8/19/25 at 2:15 PM identified that both communication with the facility and Resident #33's personal care had progressively gone downhill. In the last couple months Resident #33 looked disheveled like he/she just came out from under a bridge, with dirty long hair, dirty long fingernails and food in his/her teeth. Person #1 indicated that the resident had 3 medical appointments scheduled and for one of the appointments scheduled on 7/22/25 he/she waited for Resident #33 at the physician's office. When the resident did not show up, he/she called the facility and was told by staff that the resident was on the way. A while later, when the resident had still not shown up, he/she called the facility a second time and was told that Resident #33's transportation for the appointment was cancelled by the transportation company and the resident never actually left the facility. Although he/she did not remember who she spoke to, a staff member at the facility identified that Resident #33 was never scheduled for an appointment on 7/22/25, even though the business office had confirmed the transportation to the 7/22/25 appointment had been arranged. Person #1 stated he/she had a meeting with the interdisciplinary team on 8/5/25 to voice his/her concerns about the missed appointment and the lack concern for Resident #33's personal care. When he/she did not hear back from the facility he/she questioned the Administrator and was told that she (the Administrator) hadn't thought of responding to the concern. Person #1 indicated that he/she had not completed or signed a grievance during his/her 8/5/25 meeting. Subsequent to the meeting, the 7/22/25 missed appointment was rescheduled for 8/11/25, but Resident #33 arrived late, with food in his/her teeth, unkept hair, and an overall disheveled appearance. A review of the grievance book and grievance logs (where concerns are written when received) from July 2005 and August 2005 failed to identify any grievances logged or documented for Resident #33. Interview and record review with the Administrator on 8/20/25 at 1:58 PM identified she was the grievance officer, and it was facility policy that a grievance form be filled out when a family member or resident made a complaint, with a lead person tracking the grievance and presenting a solution. If there was a verbal complaint, then she would fill out the grievance form on the matter. Additionally, the Administrator identified that she received concerns from Resident #33's responsible party regarding personal care and transportation. Record review with the Administrator identified a grievance that was initiated on 7/23/25 regarding missed transportation, and that she was currently working on a resolution, so it remained on her desk. The grievance failed to include the lack of a haircut being provided or the concern for Resident #33's lack of personal care. The Administrator identified that she did not initiate a grievance for personal care concerns because every time she saw Resident #33, he/she looked good. The resolution to Person #1's personal appearance concern had been to provide support to Person #1 during the meeting on 8/5/25. Additionally, the Administrator identified that the responsible party was not updated on the grievance resolution because it was still on her desk and incomplete. Interview with the transportation company customer service representative on 8/21/25 at 9:32 AM identified that the transportation arrangement was not a no call no show, but that it was cancelled by the facility on 7/21/25 at 10:54 AM. Per their policy, she was unable to give specifics or disclose the name of the staff member who she identified as cancelling the appointment. Additionally, physician offices do not cancel transportation arrangements. Review of the Resident and Family Grievances Policy dated 12/23/22 directed, in part, that the Grievance Official is responsible for overseeing the grievance process. All staff involved in the grievance process should make prompt efforts to resolve the grievance, prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance. grievances may be voiced in the FOLLOWING forums: verbal complaint to a staff member, the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident to complete the form, then forward the grievance form to the grievance official as soon as practicable.

Based on interviews, review of clinical record, and facility policy for 1 of 5 (Resident #58) residents reviewed for abuse, the facility failed to report an allegation of neglect to the State Agency within the 24-hour time requirement. The findings include:Resident #58's diagnoses included fracture of the right femur, anxiety, and parkinsonism.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, required maximal assistance for toileting and chair/bed-to-chair transfers, and was dependent for personal hygiene.The Resident Care Plan (RCP) dated 8/5/2025 identified Resident #58 had Parkinson's Disease. Interventions included monitoring for constipation, and monitor/document/report side effects of Parkinson's including gait disturbance, incontinence, decline in range of motion, skin breakdown, and decline in cognitive function.Review of the Nurse Aid (NA) care card (used to direct care) in effect during August 2025, identified Resident #58 required extensive assist of 2 staff to reposition and turn in bed.Interview on 8/15/2025 at 11:33 AM with Person #7 (family member) identified on the morning of 8/13/2025 Person #7 went into the facility to visit Resident #58. The resident informed him/her that during the night shift (11:00 PM to 7:00 AM) sometime after midnight Resident #58 rang for assistance with toileting and was told to poop in his/her diaper because the aide was too busy to help. He/she further indicated that the resident sat in the dirty brief overnight and felt disrespected. Person #7 stated he/she voiced his/her concern to an unknown nurse and Medical Doctor (MD) #1 on the morning on 8/13/2025. Interview on 8/19/2025 at 11:10 AM with MD #1 identified he was notified by Person #7 on 8/13/2025 that the resident was left in a dirty brief overnight and stated he/she was upset and requested Resident #58 be checked. Further, he identified he notified the nursing supervisor (whose name he did not know) on the unit, of the allegation of neglect and that the Nursing Department was responsible for following up on the allegation. Review of the staffing schedule identified Registered Nurse (RN) #1 was the supervisor working on 8/13/2025. Interview on 8/19/2025 at 12:46 PM with Registered Nurse (RN) #1 (supervisor) identified that she worked the morning of 8/13/2025, and although MD #1 indicated he had notified the nursing supervisor on the unit, she denied being made aware of the allegation of neglect towards Resident #58 and stated if she were aware, then the allegation would have been reported (to management).Subsequent to surveyor inquiry, on 8/19/2025 at 4:17 PM, the facility generated a Reportable Event document from 8/13/2025 for the allegation of neglect. Interview with the Administrator on 8/20/2025 at 10:15 AM identified that she could not provide the surveyor with a copy of the document as it was still incomplete.Interview on 8/20/2025 at 10:44 AM with the Director of Nursing Services (DNS) identified that on 8/19/2025 she was made aware that Resident #58 did not receive care and sat in a dirty brief for hours. Further, she indicated someone at the facility had since contacted Person #7 regarding his/her concern. The DNS was unable to explain why she was not notified prior to 8/19/2025 of the allegation of neglect, or why a Reportable Event form had not been generated and sent to the SA immediately after the incident had been reported to the MD and to a staff member.Review of the facility's Accidents and Incidents policy identified in part, that an incident is any occurrence or event that causes trouble or interrupts normal procedure, for all incidents, that an accident/incident report (RE) form must be completed on the shift the accident/incident occurred, and the form will be submitted to the Director of Nursing Services.Review of the facility's Abuse policy identified in part, that reporting of all alleged violations are to be made to the Administrator, state agency, adult protective services, and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious injury; not later than 24 hours if the events that cause the allegation do not involve abuse or and do not result in serious injury.

Based on interviews, review of clinical record, and facility policy for 1 of 5 sampled residents, (Resident #58) reviewed for abuse, the facility failed to investigate an allegation of neglect. The findings include:Resident #58's diagnoses included fracture of the right femur, anxiety, and parkinsonism. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, required maximal assistance for toileting and chair/bed-to-chair transfers, and was dependent for personal hygiene.The Resident Care Plan (RCP) in effect for August 2025 identified Resident #58 had Parkinson's Disease. Interventions included monitoring for constipation, and monitor/document/report side effects of Parkinsons including gait disturbance, incontinence, decline in range of motion, skin breakdown, and decline in cognitive function.Review of the Nurse Aid (NA) care card (used to direct care) in effect during the survey identified Resident #58 required extensive assist of 2 staff to reposition and turn in bed.Interview on 8/15/2025 at 11:33 AM with Person #7 (family member) identified on the morning of 8/13/2025 Person #7 went into the facility to visit Resident #58. The resident informed him/her that during the night shift (11:00 PM to 7:00 AM) sometime after midnight Resident #58 rang for assistance with toileting and was told to poop in his/her diaper because the aide was too busy to help. He/she further indicated that the resident sat in the dirty brief overnight and felt disrespected. Person #7 stated he/she voiced his/her concern to an unknown nurse and Medical Doctor (MD) #1 on the morning on 8/13/2025. Interview on 8/19/2025 at 11:10 AM with MD #1 identified he was notified by Person #7 on 8/13/2025 that the resident was left in a dirty brief overnight and stated he/she was upset and requested Resident #58 be checked. Further, he identified he notified the nursing supervisor (whose name he did not know) on the unit, of the allegation of neglect and that the Nursing Department was responsible for following up on the allegation. Review of the staffing schedule identified Registered Nurse (RN) #1 was the supervisor working on 8/13/2025. Interview on 8/19/2025 at 12:46 PM with Registered Nurse (RN) #1 (supervisor) identified that she worked the morning of 8/13/2025, and although MD #1 indicated he had notified the nursing supervisor on the unit, she denied being made aware of the allegation of neglect towards Resident #58 and stated if she were aware, then the allegation would have been reported (to management).Subsequent to surveyor inquiry, on 8/19/2025 at 4:17 PM, the facility generated a Reportable Event document from 8/13/2025 for the allegation of neglect. Interview with the Administrator on 8/20/2025 at 10:15 AM identified that she could not provide the surveyor with a copy of the investigation as it was still incomplete.Interview on 8/20/2025 at 10:44 AM with the Director of Nursing Services (DNS) identified that on 8/19/2025 she was made aware that Resident #58 did not receive care and sat in a dirty brief for hours. Further, she indicated someone at the facility had since contacted Person #7 regarding his/her concern. The DNS was unable to explain why she was not notified prior to 8/19/2025 of the allegation of neglect, or why a Reportable Event form had not been generated as well as starting an investigation after the incident had been reported to the MD and to a staff member on 8/13/25Review of the facility's Abuse policy identified, in part, that an immediate investigation is warranted when reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation, and providing complete and thorough documentation of the investigation.

Based on observations, review of clinical records, facility policy, and interviews for the only sampled residents (Resident #43) reviewed for skin conditions, the facility failed to follow professional standards of care for the utilization of a post surgically placed wound vac. The findings include: Resident #43 was admitted on [DATE] with the included diagnoses of fusion of spine, type 2 diabetes, and hypertension.The admission Nursing assessment dated [DATE] identified that Resident #43 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was admitted with a surgical incision to the lumbar region of his/her back and required supervision with chair/bed to chair transfers and walking 150 feet. The admission Weekly Skin assessment dated [DATE] indicated that Resident #43 had a lumbar back incision and a wound vac (device to aid in healing). The admission Baseline Care Plan dated 8/3/2025 indicated Resident #43 had a surgical incision with a wound vac. Interventions included keeping the skin as clean and dry as possible, monitor wound area for signs and symptoms of infection, and monitor nutritional status. Review of a Physician's order dated 8/2/2025 directed to keep the dressing clean, dry, and intact at all times. Leave the dressing intact until 8/4/2025 then open to air. Sutures and staples were to be removed post operative on day 14. Observation and interview with Resident #43 on 8/15/2025 at 10:43 AM identified that following his/her back surgery he/she had a wound vac device placed to assist with healing. Both Resident #43 and his/her family member indicated the surgeon directed that the wound vac should have been left in place until seen by the surgeon but had been removed by the facility. A. Review of the hospital Discharge Summary and Interagency transfer documents dated 8/2/2025 failed to include the placement of the wound vac device. Interview on 8/19/2025 at 11:10 AM with Medical Doctor (MD) #1 identified that treatment orders for a wound vac would be written according to the surgeon's preference and a wound vac would only be removed if there was a problem with the wound vac or if the surgeon directed it to be removed.An interview and review of the clinical record with the Infection Preventionist, Registered Nurse (RN) #3 on 8/21/25 at 1:35 PM identified that on Resident #43's date of admission, 8/2/2025, a physician's order directed to keep the dressing clean, dry, and intact at all times. Leave the dressing intact until 8/4/2025 then open to air. RN #3 indicated that although there were no orders in the clinical record directing the care of, or the removal of Resident #43's wound vac, he assumed that, according to the physician order, the wound vac was to be discontinued on 8/4/2025 due to reading open to air. RN #3 indicated he removed the wound vac on 8/4/2025 and left the wound open to air but failed to confirm the orders for the wound vac. RN #3 indicated that according to the facility policy, a physician's order was necessary prior to the wound vac removal. RN #3 stated that since there were no orders for the removal of Resident #43's wound vac, the admitting nurse (RN #4) or himself should have contacted a provider: the physician, APRN, or the resident's surgeon who placed the device for further details, prior to removing. RN #3 indicated in retrospect he should have clarified how to care for the wound vac by calling a provider for a directive.Review of the facility's Admissions from Other Healthcare Facilities policy identified in part, that should the transferring facility fail to provide necessary medical information upon admission, implement the following: Contact the transferring facility; Implement emergency admission procedures; Notify the Medical Director and Administrator; and Document in the resident's admission notes.Review of the facility's Wound Treatment Management policy identified in part, that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders.B. Although the facility admitted Resident #43 with a wound vac for post operative wound care, the facility failed to have a policy for the provision of wound vac care. A written surveyor Resident Document Request form for a wound vac policy that had been given to the facility was returned to the surveyor indicating that the facility did not have a policy to guide staff as to how to provide care for residents admitted to the facility with a wound vac. According to the American Association of Post Acute Care Nursing, Writing Effective Policies for Long Term Care, Writing effective policies is more than a bureaucratic exercise - it is a foundational strategy for delivering safe, ethical, and compliant care. Policies ensure that regulatory expectations are met, resident rights are protected, and staff actions are guided with clarity and consistency.Attempts to reach RN #4 were unsuccessful. Although requested, the facility did not have a wound vac policy.

Based on observation, review of the clinical record, facility policy, and interviews for the only sampled residents (Resident #43) reviewed for skin conditions, the facility failed to obtain physician order to instruct care for a wound vac for a post-surgical resident. The findings include: Resident #43 was admitted on [DATE] with the included diagnoses of fusion of spine, type 2 diabetes, and hypertension.The admission Nursing assessment dated [DATE] identified that Resident #43 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was admitted with a surgical incision to the lumbar region of his/her back and required supervision with chair/bed to chair transfers and walking 150 feet.The admission Weekly Skin assessment dated [DATE] indicated that Resident #43 had a lumbar back incision and a wound vac (device to aid in healing). The admission Baseline Care Plan dated 8/3/2025 indicated Resident #43 had a surgical incision with a wound vac. Interventions included keeping the skin as clean and dry as possible, monitor wound area for signs and symptoms of infection, and monitor nutritional status.Review of a Physician's order dated 8/2/2025 directed to keep the dressing clean, dry, and intact at all times. Leave the dressing intact until 8/4/2025 then open to air. Sutures and staples were to be removed post operation on day 14.Review of an Advanced Practice Registered Nurse (APRN) order dated 8/7/2025 directed to cleanse the incision with Betadine, cover with a dressing every 8 hours and as needed for soiling, saturation, or dislodgement.Observation and interview with Resident #43 on 8/15/2025 at 10:43 AM identified that following his/her back surgery he/she had a wound vac device placed to assist with healing. Both Resident #43 and his/her family member indicated the surgeon directed that the wound vac should have been left in place until seen by the surgeon. Further, they stated that wound care was not performed daily, resulting in him/her lying on wet, bloody sheets in a wet shirt. Observation of Resident's sheets identified the bottom bed sheet had dried yellow stains in the location of where his/her wound was located.Review of the hospital discharge summary and interagency transfer documents dated 8/2/2025 failed to include the placement of the wound vac device.Interview on 8/19/2025 at 11:10 AM with Medical Doctor (MD) #1 identified that treatment orders for a wound vac would be written according to the surgeon's preference and a wound vac would only be removed if there was a problem with the wound vac or if the surgeon wanted it removed.An interview and review of the clinical record on 8/21/25 at 8:30 AM with the Infection Preventionist/Wound Nurse Registered Nurse (RN) #3 identified that when Resident #43 was admitted to the facility he could not locate physician or hospital wound care orders for the resident. He indicated that on 8/2/2025 RN #4 (the admitting nurse) entered orders for the wound to remain open to the air beginning on 8/4/2025. RN #3 stated that the wound APRN was responsible for writing wound care orders during her initial evaluation of the resident but that did not occur until 8/7/2025, and that he removed the wound vac on 8/4/2025 (3 days prior to the first APRN wound evaluation). He indicated that he was not notified by nursing that the wound had a large amount of drainage after the wound vac was removed and it was the expectation that he and the wound APRN be notified of any changes to the wound. The APRN placed new orders on 8/7/2025, after her evaluation, directing to cleanse the incision with Betadine, and cover with an dressing every 8 hours. RN #3 stated the risk of the wound not being covered and draining while it was open to air (8/4/25 through 8/7/25) increased the likelihood of delayed healing and risk of infection for Resident #43. During a second interview and review of the clinical record on 8/21/25 at 1:35 PM with RN #3 he identified that on 8/2/2025, the day Resident #43 was admitted , the Nursing admission Skin Assessment identified the presence of the wound vac. Review of the physician's orders failed to indicate that Resident #43 had a wound vac in place on admission. Because the admitting nurse, RN #4 was aware of the presence of the wound vac on admission, she should have reviewed the hospital discharge summary and the interagency discharge instructions to determine how the wound vac should have been cared for by the facility. Further, if there were no orders directing how to care for the wound vac, she should have called the hospital to review what the surgeon was directing for wound care. This information should have been written on the admission physician orders then the admitting nurse would confirm those orders with the facility physician and the order transcribed onto the Treatment Administration Record, so staff was aware how to treat Resident #43's wound. Additionally, RN #3 identified he had removed the wound vac according to the physician order dated 8/2/2015. Although the order failed to specifically indicate the removal of the wound vac, he stated that he assumed the wound vac was to be removed on 8/4/2025 due to the physician's order dated 8/2/2025 directing to leave the dressing intact until 8/4/2025 then leave the wound open to air. RN #3 indicated in retrospect he should have clarified the order for clarity with a provider. Attempts to reach RN #4 were unsuccessful.Review of the facility's Admissions from Other Healthcare Facilities policy identified in part, that should the transferring facility fail to provide necessary medical information upon admission, implement the following: Contact the transferring facility; Implement emergency admission procedures; Notify the Medical Director and Administrator; and Document in the resident's admission notes.Review of the facility's Wound Treatment Management policy identified in part, that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders.Although requested, the facility did not have a wound vac policy.

Based on observations, review of clinical records, facility documentation, facility policy, and interviews for the only sampled resident (Resident #58) reviewed for pressure ulcers, the facility failed to implement interventions for pressure ulcer prevention per the Resident Care Plan, report a change in skin integrity, and prevent the development of a pressure ulcer. Resident #58's diagnoses included fracture of the right femur, anxiety, and parkinsonism.The Nursing admission assessment dated [DATE] identified Resident #58's skin was normal in color, warm and dry, and no pressure ulcers or deep tissue injuries were present.The admission Resident Care Plan (RCP) dated 8/5/2025 identified Resident #58 was at risk for skin breakdown related to impaired mobility. Interventions included floating (not touching the mattress) heels off the bed, keep skin as clean and dry as possible, provide a pressure reducing mattress, and perform skin evaluations as ordered by the Medical Doctor (MD).MD orders dated 8/5/2025 directed to apply skin prep to bilateral heels and ensure that heels were offloaded (not touching the mattress), monitor skin for any changes to skin integrity every shift, ensure a pressure reducing mattress was in place at all times.An Advance Practice Registered Nurse (APRN) progress note dated 8/6/2025 identified no visible rashes, lesions, or wounds.Review of a Braden score (pressure ulcer risk assessment) dated 8/5/2025 identified a total score of 16 indicating low risk for pressure ulcer development.Resident #58's Skilled Nursing Assessments dated 8/7/2025, 8/8/2025, 8/9/2025, 8/10/2025, 8/14/2025, 8/15/2025, 8/16/2025, 8/17/2025, and 8/18/2025 identified his/her skin was intact with no pressure ulcers present.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, required maximal assistance for toileting and chair/bed-to-chair transfers, was dependent for personal hygiene, and was at risk, but had no current pressure injuries.Observation and interview on 8/15/2025 at 11:46 AM with Nurse Aide (NA) #4 identified that Resident #58's feet were at the end of the bed with the sheets tucked tightly under the mattress and his/her heels were not offloaded. NA #4 stated she did not realize his/her heels were not on a pillow and she would check his/her heels when she was providing him with care shortly. Interview on 8/15/2025 at 11:58 AM with Person #7 (Resident #58's family member) identified that NA #4 had informed him/her that Resident #58 had reddened areas on his/her heels that needed to be treated, and he/she was ordered special boots to wear at night. Person #7 stated he/she was very concerned about the injury that occurred to Resident #58's heels.Observation and interview on 8/18/2025 at 8:09 AM with NA #5 identified Resident #58 was lying supine in bed with his/her feet pressed against the footboard of the bed, was not wearing any boots, and his/her heels were not offloaded. NA #5 was unaware how she would know if a resident's heels needed to be offloaded and stated she was from the staffing agency and usually worked on the other side of the facility.Observation and interview on 8/19/2025 at 8:08 AM with Licensed Practical Nurse (LPN) #1 identified Resident #58 was in bed, was wearing his/her left yellow non-slip sock only, had no pillow under his/her heels to ensure offloading, and did not have heel boots in place. Heel boots were not observed in the area at the bottom of the bed, no pressure reduction mattress was noted to be on his/her bed, and his/her heels were pressed up against the footboard, with no headroom above indicating the bed was too short for him/her. LPN #1 indicated that the facility had received new beds with standard mattress and the pressure reducing mattresses had to be requested for placement. Resident #58 had not had a pressure reducing mattress placed as yet. Further, LPN #1 identified he/she had a new non-blanchable area that was dark reddish purple in color on his/her left heel area. LPN #1 indicated no staff had reported to her any changes in skin condition and she was unaware that Resident #58 had skin issues on his/her heels beginning on 8/15/2025. Although LPN #1 was aware that the resident's bed was too short, she failed to request or inform anyone to have the bed modified to accommodate the resident's height. LPN #1 indicated that she would ask the APRN to evaluate Resident #58's left heel immediately.Observation and interview on 8/19/2025 at 8:23 AM with APRN #1 identified that Resident #58 had a non-blanchable area to his/her left heel, dark red to maroon in color. APRN #1 stated that the injury was suggestive of his/her heels not being offloaded and that a factor in the development of Resident #58's pressure may have been the too short bed. Review of the nurses note written by Registered Nurse (RN) #3 (IP/Wound Care Nurse) dated 8/19/2025 identified he assessed Resident #58's heels, noting a 0.2 x 0.3 x 0 centimeter pink/maroon discoloration to the left heel, and the peri-wound was boggy (soft and spongy). The note further indicated that the resident had a past medical history of a resolved injury to his/her heel, orders were in place for heel boots to be applied by nursing, and the MD order for skin prep to Resident #58's heel was to continue.A Weekly Wound assessment dated [DATE] identified Resident #58 had a new facility acquired pressure ulcer and had interventions for a pressure reducing mattress, heel boots, and skin prep.Observation on 8/20/2025 at 8:23 AM and at 4:03 PM identified Resident #58 in bed, wearing yellow non-slip socks, not wearing heel boots, and his/her heels were not elevated off the bed. No pressure reduction mattress was on his/her bed.Interview with the Director of Nursing Services (DNS) on 8/20/2025 at 10:44 AM identified when the NA identified Resident #58's skin integrity issue on 8/15/2025, this should have been reported to the nurse and unit manager to ensure the area was assessed quickly, but licensed staff failed to perform a skin assessment until 8/19/2025 (4 days after the change was observed). Additionally, the DNS was unable to explain why staff had not consistently off-loaded Resident #58's heels or why the request for a bed extender was not placed prior to 8/19/2025 (14 days after admission) if the bed was known to be too short.Interview on 8/21/2025 at 8:46 AM with Registered Nurse (RN) #3 (the wound care nurse) identified no staff ever notified him of Resident #58's pressure ulcer per the facility policy (immediately) until 8/20/2025 (5 days later). RN #3 indicated that he had read a nurses note on 8/19/2025, evaluated his/her left heel, and determined the injury to be a new stage 1 pressure ulcer. He also noted during his evaluation that Resident #58's bed was too short. RN #3 noted that when he went in to evaluate the pressure ulcer on Resident #58's heel, he/she was not wearing boots nor were his/her heels offloaded. RN #3 further indicated that he had been made aware Resident #58's skin integrity issue had been identified on 8/15/2025 by facility staff, but the staff failed to document the information in resident #58's medical record. Additionally, RN #3 indicated Resident #58's mattress had not yet been exchanged for a pressure reducing type.A second interview on 8/25/2025 at 11:52 AM with LPN #1 identified that she placed an order on 8/19/2025 at 8:43 AM for heel boots for Resident #58 but was unable to identify why the order for boots was not placed on 8/15/2025, when the wound was first identified, and as relayed to Person #7. Review of the Treatment Administration Record (TAR) for 8/5/2025 through 8/20/2025 identified that on day shift and night shift (8/9/2025 through 8/19/2025) staff charted a pressure reducing mattress was in place at all times, and on evening shift (8/6/2025 through 8/19/2025) staff charted a pressure reducing mattress was in place at all times.A second interview on 8/25/2025 at 11:52 AM with LPN #1 identified that she placed an order on 8/19/2025 at 8:43 AM for heel boots for Resident #58 but was unable to identify why the order for boots was not placed on 8/15/2025, when the wound was first identified and as indicated by Person #7 on 8/15/2025.Observation and interview on 8/25/2025 at 12:02 PM with RN #1 (supervisor) identified Resident #58 did not have a pressure reducing mattress on his/her bed and heel boots were not ordered for him/her until 8/19/2025. RN #1 was unable to identify why staff were charting that Resident #58 had a pressure reducing mattress if one was not on the bed and why staff were not following the RCP for off-loading of heels. RN #1 indicated that the facility had purchased new beds and that Resident #58's non-pressure reducing mattress had not yet been replaced with a pressure reducing mattress.Interview and review of maintenance documents on 8/25/2025 at 12:27 PM with the Maintenance Director and Maintenance #1 identified that an order for a pressure reducing mattress for Resident #58 had never been received or placed and a pressure reducing mattress had never been placed in his/her room. Maintenance #1 further indicated the only bed related request for him/her was on 8/19/2025 when a request for a long bed was received, and there were no additional pending, cancelled, or deleted orders for him/her.Review of the facility's Pressure Ulcer Prevention Policy identified in part, that assessments will be conducted after a change in condition or after any newly identified pressure injury, and residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment.

Based on interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #9) reviewed for specialized treatments, the facility failed to communicate and collaborate with the specialized treatment center. The findings include:Resident #9's diagnoses included chronic kidney failure and end stage renal disease.A physician's order dated 10/3/24 directed for Resident #9 to receive specialized treatments 3 days a week on Monday, Wednesday, and Friday. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 was cognitively intact and required supervision and touching assistance for chair/chair-to-bed transfers. The Resident Care Plan dated 1/7/25 identified Resident #9 was at risk for impaired renal function and complications related to specialized treatments. Interventions included to monitor treatment access device for a positive bruit and thrill every shift and as needed, monitor for increase fatigue or weakness, and provide a renal diet as ordered. Review of Resident #9's clinical record and communication book from 11/13/24 to 8/15/25 was noted to have several missing communication records and the electronic health record failed to identify that the specialized treatment center had been contacted for the missing communication documentation. Interview and clinical record review with Licensed Practical Nurse (LPN) #2 on 8/19/25 at 10:46 AM identified that the process for a resident who was transported to a specialized treatment appointment was to obtain vital signs before the resident left, document on the communication form, and give the communication form to the resident to bring with them to the specialized treatment appointment. Upon the residents return, the resident would have a communication form filled out by the specialized treatment center indicating what had occurred over the course of the resident's specialized treatment such as vital signs, weight, and any new recommendations, concerns, or orders. LPN #2 indicated that if the resident returned from the treatment appointment without a communication form, the nurse could take the resident's vital signs and weight but should call the center to ensure there were no new recommendations or orders that needed to be implemented. If the specialized treatment center was contacted by the facility this would have been documented in a nursing note in the electronic health record. LPN #2 identified that Resident #9's specialized communication binder was missing 71 communication forms for the time period of 11/13/24 to 8/15/25 out of 120 attended treatments and that there was no documentation or note in the resident's health records that the facility had contacted the specialized treatment center to inquire about Resident #9's treatment status. Although LPN #2 indicated that the facility nurses were responsible to ensure appropriate communication occurred, she was unable to explain why there were 71 missing communication forms missing with no documented nursing entries indicating that the specialized treatment center was contacted for Resident #9's treatment status. Interview and clinical record review with Registered Nurse (RN) #2 (nurse supervisor) on 8/19/25 at 12:32 PM identified that residents who receive specialized treatments at an outside center were sent with a communication form and that the resident should return with the same communication form which would have a post treatment weight, vital signs, and include any new recommendations or orders. RN #2 indicated that if a resident was to return from their appointment without a communication form, then the unit nurse or nurse supervisor should have called the center to obtain the post treatment information and document the call in the nurse's progress notes. RN #2 identified that Resident #9's communication binder was missing 71 out of 120 specialized appointment communication forms for the period of 11/13/24 to 8/15/25 and that there was no documentation in Resident #9's record which indicated the treatment center was called. Although RN #2 identified that the unit/supervising nurse was responsible to ensure communication had occurred with each of Resident #9's specialized treatments, she could not explain the lack of documentation or communication forms.Interview with the specialized treatment center nurse on 8/20/25 at 12:53 PM identified that when a long-term care patient comes to their facility for treatment, the resident should come with a communication form which should have the patient's vital signs prior to their appointment. The specialized treatment center nurse indicated that post treatment, the treatment center staff document information obtained with the treatment and/or any new recommendations or orders. The form was sent back with the resident to the long-term care facility. Person #1 identified that to her knowledge, there had been no communication forms received from the long-term care for Resident #9. Additionally, the specialized treatment center nurse identified Resident #9 had attended appointments on their scheduled days with no missed appointments.Interview with the Director of Nursing Services (DNS) on 8/20/25 at 1:15 PM identified that residents receiving specialized treatment at an outside facility should be transported to the center with a communications form and should return to the facility with that form documenting results of the resident's treatment as well as any new recommendation or orders. Additionally, the DNS indicated that if the resident returned to the facility without the communication form the unit nurse or nurse supervisor was responsible to contact the specialized treatment center for post treatment information. Review of the facilities specialized treatment policy dated 12/13/22 directed in part that the facility will assure each resident receives care and services for the provision of the specialized treatment consistent with professional standards of practice including ongoing communication and collaboration with the treatment facility regarding care and services.

Based on observation, staff interviews, and facility policy while touring on the Tunxis Unit, the facility failed to ensure resident medications were properly stored and for 2 of 2 medication storage rooms, the facility failed to ensure narcotics were properly secured. The findings include:1. Observation on 8/18/25 at 11:08 AM identified Levothyroxine Sodium 200 Micrograms (mcg) 12 tablets and Doxycycline Hyclate 100 milligrams (mg), 2 tablets stored on the Tunxis Unit Nurse's Station counter. There were no staff observed in the area, but residents could be seen on the unit. The door to enter the nurse's station was open. LPN #3 was summoned by the surveyor to the Tunxis Unit Nurse Station. Interview and observation with Licensed Practical Nurse (LPN) #3 on 8/18/25 at 11:12 AM identified the Levothyroxine 200 mcg (12 tablets) and Doxycycline 100 mg (2 tablets) were left unattended and unsecured on the Tunxis Unit Nurse's Station counter. LPN #3 indicated that she left the medications on the counter because they were no longer used by the residents to whom they were prescribed, and she planned to discard them but forgot. Additionally, LPN #3 identified that she should not have left medications unattended and that it was her responsibility to ensure all medications were either secured or discarded appropriately. Review of Resident #9's order summary report identified an order for Doxycycline 100 mg oral tablet with directions to give 100 mg by mouth 2 times a day that had an end date of 8/15/25 (3 days prior to the observation). Review of Resident #52's order summary report identified an order for Levothyroxine Sodium tablet 200 mcg tablet with directions to give 1 tablet by mouth one time a day. The order had a start date of 9/2/22 and an order status of discontinued with an active order for Levothyroxine to be administered at a different dose beginning on 8/18/25. Interview with Registered Nurse (RN) #1 (unit manager) on 8/18/25 at 1:25 PM identified that resident medications should not be left unattended and unsecured due to a resident's ability to access the medications unsupervised. RN #1 indicated that once LPN #3 removed the medications from the cart to be discarded, she should have gone directly to the medication storage room and placed them in the discard medication area. Subsequent to surveyor inquiry, the medications were brought to the Tunxis unit Medication Room by LPN #3 and placed into the discard medication area. Review of the medication storage policy dated 12/14/22 directed in part that the facility must provide safe and effective storage of all drugs and biologicals in a locked storage area. 2. A. Observation and interview on 8/25/2025 at 8:44 AM with Licensed Practical Nurse (LPN) #4 identified the narcotic medication box located within the Tunxis Unit Medication Room refrigerator was affixed to a removable shelf but was not secured to the refrigerator. The medication lock box was unlocked and contained three boxes of 2mg/ml Lorazepam (a schedule IV-controlled substance). LPN #4 failed to identify why the Lorazepam had not been locked in the narcotic box or why the narcotic medication box was able to be removed from the refrigerator. Interview with Registered Nurse (RN) #2 (nurse supervisor) on 8/25/2025 at 8:54 AM identified that she was unaware that the Lorazepam had not been locked in the narcotic box within the Tunxis Unit Medication Room refrigerator and that the Lorazepam was improperly stored in an unlocked narcotic box. RN #2 was unable to identify why the Lorazepam was not properly secured. B. Observation and interview on 8/25/2025 at 9:15 AM with Licensed Practical Nurse (LPN) #6 identified the narcotic medication box located within the [NAME] Point Unit Medication Room refrigerator was affixed to a removable shelf but was not affixed to the refrigerator. LPN #6 identified that the unit manager was responsible for ensuring the box was secured to the refrigerator and unable to be removed from the Medication Room. LPN #6 failed to identify what the facility's policy directed for the securing of the narcotic box to the refrigerator. Observation and interview on 8/25/2025 at 9:22 AM with Registered Nurse (RN) #1 (unit manager) identified the narcotic medication box located within the [NAME] Point unit Medication Room refrigerator was affixed to a removable shelf but was not secured to the refrigerator. RN #1 demonstrated that the narcotic box was able to be removed from the refrigerator without difficulty. RN #1 was unable to identify why the narcotic box was not secured to the refrigerator and stated the issue of the narcotic box not being secured to the refrigerator had been discussed at a past meeting. RN #1 indicated that the Maintenance Department was responsible for the addition of a means to affix the narcotic box to the inside of the refrigerator. Observation and interview with the Director of Nursing Services (DNS) on 8/25/2025 at 9:41 AM identified the narcotic medication boxes located within the [NAME] Point and Tunxis Unit Medication Room refrigerators were improperly affixed to a removable shelf within the refrigerator but should have been secured to the refrigerator. The DNS stated both narcotic medication boxes could be removed from the refrigerators, and she could just take them home with her which was not good. The DNS was unable to identify if the facility policy directed how the narcotic boxes were to be affixed to the refrigerator. She stated she would call the Director of Maintenance to immediately and properly secure the narcotic boxes to the refrigerator with a chain. Review of the facility's Controlled Substances Policy identified in part that controlled substances must be stored in the Medication Room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. The Controlled Substances Policy failed to identify that controlled substances stored in the refrigerator must be in a locked box that is securely affixed to the refrigerator per the requirement.

Based on interviews, review of clinical records, review of photographs, and review of facility policy for 1 sampled resident (Resident #43) reviewed for discharge and 2 additional previously discharged residents (Resident #48 and Resident #89) the facility failed to ensure protected personal information remained secured and private. The findings include:Interview with Person #6 (Resident #43's family member) on 8/18/2025 at 11:31 AM identified that upon Resident #43's discharge on [DATE], he/she was sent home with a bag of prescriptions medications for Resident #48 and Resident #89. The medications were given to Person #6 by Registered Nurse (RN) #1. Person #6 stated that he/she had just returned the incorrect prescriptions to the Administrator. Person #6 indicated that although none of the incorrect other resident medications had been taken by Resident #43, he/she was very upset that the wrong medications were sent home at discharge and that he/she had taken pictures of the medications to report to the State Agency (SA) and would subsequently be providing the pictures to the surveyor.Review of Person #6's photographs identified a bag labeled with Resident #48's name, date of birth , and medical record number. The bag contained Dorzolamide-Timolol eye drops, Pilocarpine eye drops, and Megestrol Acetate oral suspension with Resident #48's full name and prescription information as well as Breyna 160-4.5 MCG HFA Inhalation Aerosol labelled with Resident 89's full name and prescription information. 1. Resident #43's diagnoses included fusion of spine lumbar region, type 2 diabetes, and hypertension.A review of physician orders from 8/2/2025 through 8/20/2025 failed to identify that Resident #43 had been prescribed any of Resident #48 or Resident #89's medications that had been given to and photographed by Person #6.2. Resident #48's diagnoses included glaucoma, malignant neoplasm of the lung, and malignant neoplasm of the bone.A physician's order dated 7/30/2025 directed to administer Dorzolamide HCL-Timolol Mal Ophthalmic solution 1 drop in the right eye 2 times a day for glaucoma, Megestrol Acetate Oral Suspension 400 mg/10ml give 10 ml by mouth 1 time a day for appetite stimulator, and Pilocarpine HCL Ophthalmic Solution 2% 1 drop in right eye 2 times a day for glaucoma. The medications prescribed by the physician matched the medications labeled with Resident #48's information, and which were given to Resident #43 upon discharge. 3. Resident #89's diagnoses included asthma, Type 2 Diabetes, and chronic obstructive pulmonary disease (COPD).A physician's order dated 8/5/2025 directed to administer Budesonide-Formoterol Fumarate Inhalation Aerosol (Breyna) 2 puffs inhale orally two times a day for wheezing. The medications prescribed by the physician matched the medication labeled with Resident #89's information and which were given to Resident #43 upon discharge.Interview with the Administrator on 8/20/2025 at 8:45 AM identified that Person #6 had received and brought home different residents medications upon discharge. The Administrator stated after receiving the medications from Person #6, she gave the medications to RN #1 and referred Person #6 to RN #1 for follow-up. Interview on 8/20/2025 at 8:57 AM with RN #1 identified that she was responsible for sending the incorrect medications home with Resident #43, that protected personal information for Resident #48 and Resident #89 was provided to Resident #43 in error, and that she had not read the bottles before giving the wrong medications to Resident #43 due to not wearing her glasses. Further, RN #1 identified that she did not think to notify Resident #48 or Resident #89 that their protected personal information had been provided to an unauthorized individual. Interview with the Director of Nursing Services (DNS) at 10:44 AM on 8/20/2025 identified that on 8/20/2025 she had overheard staff speaking about RN #1 sending the wrong medications home upon Resident #43's discharge. She stated that neither staff nor the Administrator had reported the incident prior to what was overheard. The DNS indicated that upon discharge, residents are to receive education on each medication being sent home, and the resident was to sign they received education on every medication. The DNS was unable to explain why other resident medications were sent home with Resident #43 or why the residents/family members had not been notified of the improper release of protected personal information to an unauthorized individual (Resident #43).Although requested the facility did not have a policy for protecting health information.Review of the facility's Discharge Medications Policy identified in part that the nurse charge shall verify that medications are labelled consistent with current physician orders, the nurse will complete the medication disposition record including the resident's name, the name and prescription number of each medication, and the signatures of the person receiving the medications and the nurse releasing the medications. Further the nurse will review medication instructions with the resident, family member, or representative before the resident leaves the facility.

Based on observations, review of the clinical record, facility policy, and staff interviews for 2 of 2 sampled residents (Resident #83, and #89) reviewed for blood glucose testing, the facility failed to clean and disinfect a Glucometer (glucose testing) device per the manufacturer's instructions for use. The findings include:Interview with RN #3 (Infection Prevention Nurse) on 8/15/2025 at 11:58 AM identified that glucometers are to be cleaned between every use and as needed with the Super Sani Disinfectant with the purple top lid. 1. Resident #83's diagnoses included type 2 diabetes, hypertension, and osteoarthritis.The Nursing admission assessment dated [DATE] identified Resident #83 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, required maximal assistance with his/her personal hygiene, and required extensive assistance with walking in his/her room.A physician's order dated 8/1/2025 directed to obtain a blood glucose level by fingerstick and to administer lispro (insulin) 100 unit/milliliter per a sliding scale subcutaneously before meals and at bedtime.The Resident Care Plan (RCP) dated 8/3/2025 identified Resident #83 had diabetes mellitus and included interventions of fasting serum blood sugar as ordered by the doctor, monitoring compliance with diet, and diabetes medication as ordered by doctor.During an observation and interview with Registered Nurse (RN) #5 on 8/19/2025 at 5:41 AM, she conducted blood sugar monitoring for Resident #83 using a blood glucose monitor. Following the procedure RN #5 obtained a wipe from a blue top container labelled Antimicrobial Hand Sanitizer, alcohol 67.9% and proceeded to clean the glucose meter with the wipe. RN #5 stated that the wipe she used to disinfect the glucose meter was the correct wipe for cleaning glucose monitors and were the wipes she had always used. She further stated that the glucose monitors were used on multiple residents on the unit and that the unit nurse using the blood glucose meter was responsible to ensure that correct wipes were used for disinfecting. Although the surveyor stopped RN #5 and had her read the label pointing out the contents were hand sanitizer, RN #5 insisted she was using the correct wipes and during a constant observation following Resident #83's blood glucose monitoring, went on to check Resident #89's blood sugar.2. Resident #89's diagnoses included Type 2 Diabetes, chronic obstructive pulmonary disease, and systemic [NAME] Erythematosus.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #89 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition and required moderate assistance with personal hygiene and rolling left and right in bed.The Resident Care Plan (RCP) dated 8/4/2025 identified Resident #89 was at risk for skin breakdown related to diabetes mellitus but failed to include interventions for blood glucose testing and monitoring. A physician's order dated 8/6/2025 directed to obtain a blood glucose level 4 times a day for diabetes mellitus.Observation of RN #5 on 8/19/2025 at 5:55 AM with Resident #89 identified that she continued on to Resident #89 and performed a blood glucose test with the same monitor used to test Resident #83 and that had been cleaned with the container labeled Antimicrobial Hand Sanitizer, alcohol 67.9%. Following Resident #89's blood glucose test, RN #5 placed the glucose monitor on a paper towel on top of the medication cart. During constant observation of RN #5, on 8/19/2025 from 5:55 AM through 6:29 AM the glucose monitor remained on the paper towel on top of the medication cart until she moved the glucose meter to store it in a drawer in her medication cart without the benefit of disinfecting. RN #5 was stopped again by the surveyor. RN #5 indicated that she had been unaware she had failed to appropriately cleanse the glucose meter prior to placing it in the medication cart drawer. Further, RN #5 identified that the glucose meter should have been disinfected after use and before storing it in the medication cart.An interview with the Director of Nursing Services (DNS) on 8/20/2025 at 10:44 AM identified the correct wipes used to clean the facility's glucometer should be either the purple top disinfection wipes or a bleach wipe per the glucometer manufacturer's recommendations. Further she identified that glucometers should always be cleaned by nurses between residents. The DNS was unable to explain why RN #5 failed to use the correct manufacturer directed disinfection wipes and failed to appropriately clean the glucometer between residents. The DNS indicated that staff had just been in-serviced on proper glucose meter usage 2 days ago and that RN #5 had signed as attending the education. Review of the Glucometer Disinfection Policy identified that glucometers should be disinfected after each use with a disposable germicidal wipe. If a germicidal wipe is not available, the glucometer is to be cleaned with an alcohol prep pad and disinfected with a solution of 1:10 bleach.

Based on clinical record reviews, facility documentation, facility policies and interviews for two of three sampled residents (Residents #1 and #2) who were reviewed for a resident-to-resident altercation, Resident #1 had the right to be free from physical abuse by Resident #2. The findings include: Resident #1's diagnoses included Alzheimer's Disease, transient ischemic attack, and generalized muscle weakness. The Resident Care Plan dated 1/4/24 identified Resident #1 had difficulty communicating, impaired cognitive function and wandered into other residents' rooms. Interventions directed to anticipate and meet needs, administer medications as ordered, discuss changes with family regarding resident's abilities and needs, redirection techniques, and provide activities that interested and engaged the resident. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, exhibited wandering behaviors, occasionally rejected care provided, and required supervision with walking and transferring. The nurse's note dated 3/12/24 at 3:10 PM identified the 7AM-3PM Nursing Supervisor was called to assess Resident #1 who was observed on the floor in the common area of the unit. The note indicated Resident #1 had sustained two (2) lacerations to the head which were bleeding, the Advanced Practice Registered Nurse (APRN) was in the building and assessed Resident #1. The physician's note dated 3/12/24 at 1:00 PM identified Resident #1 was pushed by Resident #2 and fell , hitting his/her head on furniture. The note identified Resident #1 sustained two (2) scalp lacerations and was minimally cooperative with the neuro exam, so the APRN sent Resident #1 to the Emergency Department. The social worker's note dated 3/13/24 at 3:16 PM identified Resident #1 was alert, confused at baseline, and did not have any complaints or noted changes to his/her mood or behaviors. Resident #2's diagnoses included dementia and type 2 diabetes. The current Resident Care Plan identified on 9/21/23 a care plan was initiated to address Resident #2's exhibited poor impulse control with a history of inappropriate verbal peer interactions. Interventions directed to evaluate the nature and circumstances that trigger behaviors, psychiatric consults as needed, observe for non-verbal signs of aggression, and redirect the resident from the environment if needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made poor decisions regarding tasks of daily life and was independent with activities of daily living. The nurse's note dated 3/12/24 at 3:04 PM identified fell ow residents reported Resident #2 had pushed another resident, Resident #1, to the floor which resulted in Resident #1 getting injured. The Facility Reported Incident form dated 3/12/24 at 1:45 PM identified Resident #2 stated he/she pushed me, so I pushed him/her. The report indicated Resident #1 sustained a laceration to the top of the scalp and left side of the scalp. The nurse's note dated 3/12/24 at 5:37 PM identified Resident #2 was sent to the Emergency Department for evaluation due to combative behavior. The Emergency Department note for 3/12/24 identified that Resident #2 was combative to the Emergency Medical Services and was restrained while being transferred. The notes identified Resident #1 was evaluated by psychiatry, given Tylenol, and returned to the facility with no new orders. The psychiatry note dated 3/12/24 identified Resident #2 was seen due to a resident-to-resident altercation. The note identified Resident #2 had been having an increase in restlessness since the gradual dose reduction of Zyprexa was begun on 2/24/24. The APRN directed to return the Zyprexa to the prior dose and to add Trazodone 5 milligrams at bedtime as needed for two (2) weeks. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 4/1/24 at 11:45 AM identified she was working on 3/12/24 when the physical altercation occurred between Resident #1 and Resident #2. RN #1 identified she was called to the unit by the charge nurse, she found Resident #1 lying on his/her back in the atrium area of the unit with his/her head resting on the base of an armoire, and Resident #1's head was bleeding. RN #1 indicated she was told by a laundry staff member that Resident #2 was getting mad at Resident #1 because Resident #1 was circling around Resident #2 and his/her friends mumbling something. RN #1 identified Resident #2 wanted Resident #1 to stop and when Resident #1 did not stop, Resident #2 pushed Resident #1. RN #1 indicated Resident #1 did not have a history of physical aggression, however Resident #1 did wander around and mumble saying nonsensical words. RN #1 identified Resident #2 had a history of becoming aggressive. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 4/1/24 at 12:10 PM identified on 3/12/24 she heard a commotion and someone from laundry called out saying Resident #1 had fallen. LPN #1 identified other residents in the area witnessed the fall and stated that Resident #2 had pushed Resident #1. LPN #1 indicted she had seen Resident #2 purposely nudge or bump into others if they were in his/her way or if he/she didn't like what the resident had to say, the staff would attempt to redirect Resident #2 when these behaviors occurred, and Resident #1 was redirectable depending on his/her mood. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 4/1/24 at 12:35 PM identified although she did not witness the fall, she heard the commotion and went to Resident #1. NA #1 identified there were many residents present and they kept pointing to Resident #2 stating he/she pushed Resident #1. Interview with the day shift laundry staff member on 4/1/24 at 12:50 PM identified while she was putting clothes away on the unit, she heard Resident #1 and #2 arguing and Resident #2 telling Resident #1 to get away from him/her and then saw Resident #1 on the floor bleeding. The laundry staff member indicated she checked on Resident #1 and called for help. Review of the facility policy for Abuse identified that the facility prohibits abuse. Review of the facility Resident's [NAME] of Rights identified residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for end of life, the facility failed ensure the responsible party was notified timely when a change in skin integrity was identified. The findings include: Resident #1 was admitted with diagnosis that include schizoaffective disorder, generalized muscle weakness and senile degeneration of the brain. The Resident Care Plan (RCP) dated 9/22/2023 identified Resident #1 was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Interventions directed to float heels while in bed, low loss mattress, and to evaluate for skin problems. A quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assistance for bed mobility, was non-ambulatory, was at risk for pressure ulcers and had one (1) Stage III pressure ulcer. Clinical record review identified Resident #1 had a court appointed Conservator. A facility consultant wound Nurse Practitioner (NP) consultation dated 10/23/2023 identified an initial assessment of a right foot deep tissue injury (DTI), non-blanchable, deep red, maroon/purple discolored pressure ulcer, 0.5 centimeters (cm) length by one (1) cm width with no measurable depth. The note directed to cleanse the wound with wound cleanser and protect the peri wound with no sting-skin prep twice a day and leave open to air. Review of the clinical record failed to identify the responsible party was notified of the new DTI. Interview with RN #1 on 3/6/2024 at 12:49 PM, the infection control/wound nurse in October 2023, identified she was responsible to make rounds with the wound NP and the NP would complete the documentation. RN #1 further indicated the nurse on the unit was responsible to contact the responsible party with any updates, and then write a note in the clinical record to identify the notification was completed. RN #1 indicated although she did not recall the new area for Resident #1, she identified the charge nurse should have notified the family. Interview with LPN #1 on 3/6/2024 at 1:30 PM identified she was the charge nurse on 10/23/2023 when Resident #1's new skin area was identified, and further indicated as the charge nurse she would be responsible to notify the family. Although LPN #1 indicated she could not recall if she notified the family, she stated if she had notified the family, she would have written a nursing note to identify that it was done; if it was not documented, she indicated it was not done. Interview with the DON on 3/6/2024 at 2:00 PM identified that if a resident had a new pressure area, notification to the physician and family was necessary. The DON was unable to provide documentation that the family was notified, and indicated she did not know why it was not completed. The facility Change in Condition: Notification of, Policy dated 6/1/2021, directed in part, the facility must immediately inform, the resident's health care authority, Health Care Decision Maker, where there is a significant change in the resident's physical status or when there is need to commence new treatment.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for end-of-life care, the facility ensure a complete and accurate record to include records prior to facility ownership, to include documentation of ADL care, documentation of hospice services and documentation of an assessment of death. The findings include: Resident #1 was admitted with diagnosis that include schizoaffective disorder, generalized muscle weakness and senile degeneration of the brain. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Interventions directed to float heels while in bed, low loss mattress, and to evaluate for skin problems. A quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assistance for bed mobility, was non-ambulatory, was at risk for pressure ulcers and had one (1) Stage III pressure ulcer. Clinical record review identified Resident #1 had a court appointed Conservator. 1. Clinical record review failed to identify any documentation for ADLs during [DATE]. Interview and record review with the Administrator [DATE] at 1:15PM identified although the ADL documentation was requested from the facility, the Administrator indicated due to a change in ownership that occurred during [DATE], the ADL documentation for Resident #1 was not available as part of the medical record for review. The Administrator indicated a request was made to the prior owners for the documentation to be sent to the facility and indicated it should be a part of the Resident's accessible medical record. The facility ADL Policy dated [DATE] directed in part, that documentation of ADL care was recorded in the medical record and was reflective of care provided by the nursing staff. ADL care will be documented in real time. 2. The RCP identified that Resident #1 was on hospice services, with a start date of [DATE]. The RCP directed to assess for signs of discomfort, provide nonpharmacological and medications as needed. A Hospice physician order dated [DATE] recertified hospice level of care, and directed hospice staff provide all core services as outlined in the hospice plan of care. Interview with the DON on [DATE] at 1:00 PM identified that the facility had changed ownership in October of 2023 and that a request was made to the prior owner corporate office to send the ADL documentation for Resident #1 that was currently not available. The hospice services would also be contacted to request the missing hospice documentation since the facility was unable to locate that documentation at this time. Resident #1's medical record included the hospice plan of care and recertification for [DATE] but lacked documentation of the hospice election form and any hospice services of any care provision during the month of [DATE]. The facility Hospice Policy dated [DATE] directed in part, the facility obtains the hospice election form from hospice. The facility policy Nursing Documentation dated [DATE] directed in part that the purpose of the policy was to communicate residents' status, provide complete, comprehensive, and accessible accounting of care and monitoring provided. All resident information was documented, scanned, or entered into the clinical record. 3. A physician's order dated [DATE] directed do not resuscitate (DNR), do not intubate (DNI), transfer for acute injury only, and RN Pronounce (RNP - RN may pronounce death). Review of a nursing note dated [DATE] at 5:57 PM identified Resident #1 had expired at 5:49 PM. The note further identified APRN #2 and Person #2 were notified of the death, however the note failed to identify Resident #1 was assessed at his/her time of death by an RN to pronounce the death. During an interview with RN #2 on [DATE] at 4:24 PM, RN #2 indicated he/she had pronounced Resident #1's death on [DATE], notified Resident #1's family immediately after the pronouncement, and she failed to document Resident #1 was assessed at his/her time of death. RN #2 further indicated that facility policy directed to assess residents at their time of death, which involved checking vitals, respirations, apical pulse, chest rising/falling, skin color, eye dilation, and relaxation of muscles, and to document the assessment in the resident's chart. RN #2 indicated he/she forgot to document the assessment in the resident's chart. Review of the Pronouncement of Death policy dated [DATE] directs the registered nurse (RN) who has determined and pronounced death will document the clinical criteria for such determination and pronouncement in the patient's medical record which include a description of the discovery of the patient, any treatment the patient had undertaken, findings from assessment (presumptive and conclusive signs identified) such as no carotid and peripheral pulse, pupils fixed and non-reactive to light, no response to tactile stimuli, no respirations for one full minute, no heart sounds for one full minute, the date and time of death, individuals notified of the patient's status/death, and results of any communications. Interview with the DON on [DATE] at 1:00 PM identified that the facility had changed ownership in October of 2023 and the facility did not have access to the prior owner's electronic medical records (and had no paper copies). The DON indicated a request was made to the prior owner's corporate office to send copies of the requested medical records that the facility did not have available. Review of facility Change of Ownership Pre-Licensure Consent Order dated [DATE] directed in part, any records maintained in accordance with any state or federal law or regulation or as required by this Order shall be made available to the INC and the Department upon request.

Based on observations, record review policy and interviews for 2 of 6 residents (Resident #9 and Resident #62) reviewed for pressure ulcers, the facility failed to prevent the development of pressure ulcers and failed to provide the necessary treatment and services for residents with a pressure ulcer. For Resident #9, the facility failed to prevent the development of a pressure ulcer in a dependent resident, failed to ensure timely turning and repositioning and off-loading/floating (removal of pressure from a body part), failed to conduct pressure ulcer risk assessments per the facility policy, and failed to conduct weekly skin assessments. For Resident #62, the facility failed to conduct an initial pressure ulcer assessment, failed to obtain initial pressure ulcer measurements, failed to inform the wound nurse of the development of a new pressure ulcer, and failed to ensure off-loading/floating of a pressure area. The findings include: 1. Resident #9 's diagnoses included pneumonia, urinary tract infection, dementia, and bipolar disorder. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #9 was severely cognitively impaired and required supervision with bed mobility and transfers. Additionally, Resident #9 was not at risk for pressure injury or development, a pressure reducing bed and chair were in use, and Resident #9 did not have a turning or repositioning schedule. The Resident Care Plan dated 10/10/23 identified a risk for skin breakdown related to impaired mobility. Interventions directed to encourage the resident to offload/float heels while in bed and encourage the resident to turn and reposition frequently. Review of the nurse aid flow sheets dated 10/1/23 to 10/4/23 identified that Resident #9 had been independent with bed mobility. Review of APRN orders dated 10/5/23 through 10/10/23 directed to administer antibiotics to treat Resident #9's urinary tract infection and pneumonia. APRN notes dated 10/5/23 through 10/10/23 identified that Resident #9 was seen in follow-up of pneumonia, urinary tract infection, acute kidney injury on chronic kidney disease, anemia, and decreased platelet count. Resident #9 was noted to be fatigued, lacked an appetite, was not taking food or fluids well, had increased confusion, dysuria (pain on urination), increased lethargy, and weakness/tiredness due to his/her infection. A change in condition nurse's note dated 10/8/2023 at 2:48 AM identified Resident #9 had an exacerbation (worsening of an already present) respiratory condition and that antibiotics were being used to treat pneumonia. Resident #9 was noted to be alert/verbal, appeared comfortable, was resting in bed without issue, and was provided with incontinent care and repositioning in bed, however the note failed to indicate encouragement or assistance with heel off-loading. Review of the nurse Situation, Background, Assessment, and Recommendation documentation dated 10/10/23 at 10:50 AM identified that Resident #9 was noted with generalized weakness. Review of the nurse Situation, Background, Assessment, and Recommendation documentation dated 10/11/23 identified Resident #9 was resting in bed without issue, was weak, incontinent care and repositioning in bed was provided, and the resident had a peripheral intravenous catheter inserted at 1:30 AM for antibiotic administration. The documentation failed to indicate encouragement or assistance with heel off-loading. Review of the facility Skin and Wound evaluation dated 10/13/23 identified a new, in house acquired, unstageable pressure ulcer to the left heel that was 100 percent eschar (hardened dead tissue debris) measuring 3.5 centimeters (cm) by 4.6 cm. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 was moderately cognitively impaired and required extensive assistance of 2 staff with bed mobility and transfers. Additionally Resident #9 had one unstageable pressure ulcer and was not on a turning or repositioning program. Review of the NA flow sheets from 10/5/23 to 10/13/23 identified that Resident #9 had required substantial/maximal assistance to total dependence on staff for bed mobility. The revised Resident Care Plan dated 10/13/23 identified that Resident #9 was at risk for skin breakdown related to fragile skin. Interventions directed to encourage the resident to offload/float heels while in bed and encourage to turn and reposition frequently. The care plan failed to reflect Resident #9's increased need for assistance as documented on the NA flow sheet. An APRN note dated 10/13/23 identified Resident #9 was seen in follow-up. Nursing staff reported a new blister to Resident #9's left heel noted during care. Resident #9 admitted to discomfort and was noted to have large intact blister to the left heel filled with light blue/red fluid. The plan included applying skin prep twice daily, off load heels at all times, and the wound team was to follow up. Additionally, Resident #9 admitted to discomfort. An APRN order dated 10/13/23 directed to apply skin prep to Resident #9's left heel unstageable pressure ulcer twice daily and keep heels elevated at all times. Review of the transcribed APRN order dated 10/13/23 directed to off load heels every day and evening shift. The transcribed order failed to include the night shift. Review of the wound care provider note dated 10/16/23 identified a left heel, pressure induced, deep tissue pressure injury that measured 6.5 cm x 8 cm (an increase in size from the initial measurement from 3 days prior). The plan included cleansing the wound with normal saline, apply xeroform, apply an abdominal pad followed by kerlix, change twice weekly, and ensure off-loading per facility protocol. Review of the facility wound tracking log and wound care provider note dated 10/30/23 identified that Resident #9 had refused to be seen the previous week. The wound care provider note identified a left heel deep tissue pressure injury that measured 5.8 cm by 7.5 cm and modifying factors included poor off-loading. Review of the weekly wound care provider measurements dated 11/6/23 identified the left heel pressure ulcer measured 6.5 cm x 7.0 cm (an increase in size from 7 days prior.) Every 15 minute observations on 11/6/23 from 10:45 AM to 1:50 PM, identified Resident #9, lying on his/her left side, in bed, with his/her head at the foot of the bed. A pillow was noted on the floor at the foot of the bed. Resident #9 had 1 slipper sock on his/her left foot, and both heels were noted to be in direct contact with the mattress throughout each 15 minute observation time. Although staff was observed to enter the room on 4 separate occasions for 30 seconds to 1 minute, the Resident's position remained unchanged and Resident #9's left heel (the heel with the pressure ulcer) remained in direct contact with the mattress without the benefit of off-loading. Interview with NA #5 on 11/6/23 at 1:45 PM identified that she had looked in on Resident #9 after breakfast. The next time she saw Resident #9 was when she dropped off his/her lunch tray. NA #5 told Resident #9 that lunch was available, Resident #9 was noted to open his/her eyes, lift his/her head, and returned back to sleep. NA #5 denied she had offered Resident #9 assistance to reposition or move prior to leaving the room after breakfast or when dropping off Resident #9's lunch tray. Interview with APRN #1 on 11/6/23 at 1:10 PM identified that Resident #9 had been reasonably independent prior to becoming ill around 10/5/23 but had been bed bound following the development of his/her illness. APRN #1 stated after observing Resident #9's new pressure wound, she directed skin prep and off-loading at all times (off-loading was transcribed to indicate the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts only). APRN #1 indicated that once Resident #9 had declined due to his/her illness, potentially, measures for off-loading such as booties or off-loading pillows would have been appropriate. APRN #1 stated that pressure ulcers develop as a result of not off-loading heels, and that potentially, the pressure ulcer could have been avoided if preventative measures had been put in place. Interview with NA #6 on 11/6/23 at 1:50 PM identified that prior to becoming ill Resident #9 was fiercely independent. NA #6 stated that Resident #9 had developed his/her pressure ulcer a few weeks ago when s/he was sick. NA #6 indicated that when Resident #9 became sick, s/he required full care. Although Resident #9 was able to use the grab bar to turn and reposition his/her upper body, s/he required full assistance with his/her lower extremities to reposition. NA #6 indicated that in order to prevent Resident #9 from developing a pressure ulcer, pillows were to be placed for off-loading, however, NA #6 was unable to explain why Resident #9's left heel had been observed resting on the mattress for 3 hours. Interview and review of Resident #9's clinical record on 11/6/23 at 2:20 PM with LPN #2 identified Resident #9 had developed the left heel pressure ulcer when s/he was not feeling well, wasn't moving as much, and was not getting out of bed. LPN #2 indicated that Resident #9 was relatively independent prior to becoming ill but was unable to find supporting documentation that measures to prevent pressure ulcer development were implemented when Resident #9 became more dependent on staff. LPN #2 identified that when preventative measures were put in place, they were typically directed by the physician/APRN and were written on the Medication Administration or Treatment Administration Records for staff to implement and sign as being completed. LPN #2 identified that Resident #9 was known to refuse care at times, but she was unable to find documentation that Resident #9 had been refusing off-loading. Additionally, if Resident #9 had refused off-loading during her shift, she would have expected the NA to notify her immediately so she could intervene. LPN #2 indicated that although she had given Resident #9 medications around 1:00 PM, she had not repositioned or offered off-loading assistance to Resident #9 and staff had not reported that Resident #9 had refused assistance. Interview with NA #4 on 11/6/23 at 2:38 PM identified that she had last seen Resident #9 between 9:00 AM and 9:30 AM when s/he refused care at the time. The next time NA #4 entered the room was approximately 2:10 PM. NA #4 indicated that when any resident has a pressure ulcer, the foot should be propped up but that Resident #9 didn't have sufficient off-loading under his/her feet when she arrived to provide care. Further, NA #4 indicated that initially the unit had 4 staff scheduled for 11/6/23, but that 1 NA had been taken to work on the other unit. NA #4 indicated that everybody was responsible to ensure that resident heels were off-loaded and that it was common sense. NA #4 indicated that Resident #9's heels were not appropriately off-loaded because it was a crazy day due to staffing issues, and she was unable to get to assist Resident #9 with care needs any sooner than she had. Interview and review of Resident #9's clinical record with the Wound Nurse, RN #3, on 11/8/23 at 9:45 AM identified that she became responsible for the wound program on 10/16/23. RN #3 identified that, according to the care plan, Resident #9 had been encouraged to independently perform turning and positioning and off-loading since 2/12/23. RN #3 stated that when Resident #9 became ill, and more dependent on staff, the clinical record failed to reflect new interventions to prevent pressure ulcer development. Although Resident #9's left heel pressure ulcer had become worse and increased in size between 10/13/23 and 10/16/23, and again between 10/30/23 and 11/6/23, no new interventions were implemented to prevent further deterioration. RN #3 identified a nurse's note she had written on 11/7/23 indicating that she had offered Resident #9 an off-loading boot on 10/23/23, which was subsequently refused by Resident #9, but failed to indicate further attempts to provide Resident #9 with other alternatives to prevent deterioration of his/her pressure wound. Further, RN #3 had thought about providing the resident with a different type of mattress but had not followed through. RN #3 was unable to find a pressure ulcer risk assessment prior to or upon development of Resident #9's left heel pressure ulcer, but that upon development Resident #9 should absolutely have had a risk assessment performed. Additionally, although RN #3 indicated that the facility should be documenting weekly skin assessments, the facility had not conducted any weekly skin assessments in some time. Interview and review of Resident #9's clinical record with the DNS on 11/13/23 at 1:34 PM identified that when a resident has a newly developed pressure ulcer, a pressure ulcer risk assessment should be conducted. The DNS identified that Resident #9's last pressure ulcer risk assessment had been completed on 2/14/2019. The DNS indicated that the facility policy was to conduct risk assessments quarterly and with a change in condition. Although the DNS indicated new interventions should have been put in place first when Resident #9 had a decline in bed mobility, after the pressure ulcer developed, and with a deterioration of the pressure injury, the DNS failed to identify any new measures had been documented or implemented. Additionally, the DNS identified that weekly skin checks should have been conducted on Resident #9's scheduled bath/shower days, however, Resident #9 had not had a weekly skin assessment conducted since 8/4/2020. 2. Resident #62's diagnoses included dementia with agitation, muscle weakness and Type II diabetes mellitus. A Braden skin risk assessment completed on 7/30/23 identified a score of 14 indicating that Resident #62 was at high risk for pressure ulcer development. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #62 was severely cognitively impaired and required the assistance of 2 staff with bed mobility and transfers. Additionally, Resident #62 was identified as at risk for pressure ulcer development and had a current pressure injury to the right heel. The Resident Care Plan dated 9/18/23 identified that Resident #62 was at risk for skin breakdown related to a history of a pressure ulcer, advanced age, nephrostomy tube, decreased activity, and impaired cognition, Interventions included to turn and reposition every 1-2 hours, observe skin condition daily with care and report abnormalities, off load/float heels (remove pressure) using heel boots at all times, and conduct a weekly skin check by licensed nurse. A physician's order originally dated 8/23/23 and still in effect as of 11/7/23 directed heel boots at all times, remove every shift for skin checks, daily hygiene, and treatment. Review of the Treatment Administration Record from 10/1/23 through 11/7/23 identified that Resident #62 had been directed to wear heel boots to both lower extremities, at all times, and that facility staff had signed off that the heel boots were in place every day on every shift. Review of the facility weekly skin check dated 10/26/23 indicated that Resident #62 had a previously identified pressure ulcer of the heel but failed to indicate which heel was affected. A new physician's order dated 10/27/23 directed skin prep to be applied to the left heel twice daily. Observation on 10/31/23 at 1:08 PM identified Resident #62 sitting in wheelchair wearing slipper socks without the benefit of heel boots. Review of the facility provided current resident pressure ulcer tracking received on 11/1/23 failed to indicate that Resident #62 had a pressure ulcer. Interview and review of facility documentation with the wound nurse, RN#3, on 11/1/23 at 11:43 AM identified that Resident #62 previously had a pressure ulcer of the right heel which developed on 8/30/23 but had subsequently healed as of 9/18/23. RN #3 indicated that her tracking documentation failed to identify that Resident #62 had a current pressure ulcer to his/her right or left heel. RN #3 indicated that she would have to review the clinical record. Re-interview with RN #3 on 11/1/23 at 12:05 PM identified that after reviewing Resident #62's clinical record, that Resident #62 did have a new facility acquired, stage 2 pressure ulcer of the left heel that had been identified on 10/26/23. RN #3 indicated that facility staff had never informed her of Resident #62's newly developed pressure ulcer. Further, RN #3 was unable to locate documentation in the clinical record, nursing notes, of the new pressure ulcer or that the left heel pressure ulcer had been measured since 10/26/23, when the pressure ulcer had been identified. Subsequent to surveyor inquiry, RN #3 indicated she would obtain left heel pressure ulcer measurements. Interview and review of facility documentation with the DNS on 11/1/23 at 12:41 PM indicated an APRN note dated 10/26/23 identified a new pressure ulcer to Resident #62's left heel. The APRN ordered skin prep to be applied twice daily beginning on 10/27/23, off-loading heels at all times, and the wound team was to follow-up. The DNS indicated that per facility policy her expectation with a new pressure ulcer, would have been that staff conduct a full skin assessment, document wound measurements in the medical record, conduct a change in condition assessment, and notify the wound nurse. Observation on 11/1/23 at 12:49 PM, identified Resident #62 sitting in wheelchair wearing slipper socks without the benefit of heel boots. Review of the revised Resident Care Plan dated 11/1/23 indicated a potential for impaired skin integrity as evidenced by Braden scale (used to predict pressure ulcer risk) and that Resident #62 was at high risk for pressure ulcer development. Interventions included the use of heel boots to bilateral lower extremities while in bed and wound care to the left heel as ordered. Although the Resident Care Plan indicated heel boots to bilateral lower extremities while in bed, the physician order continued to direct heel boots at all times and the new APRN order dated 10/27/23 directed off-loading heels at all times. Review of RN #3's wound note dated 11/1/23 at 2:04 PM identified a new left heel blister (pressure ulcer) measuring 4 (centimeters) cm by 4 cm, lacking depth. A new treatment order included skin prep twice daily and offloading boots while in bed. Although the wound note identified a change to the physician's order, review of the physician's orders failed to indicate that the physician had changed the order from wearing the boot at all times to wearing the boot while in bed. Observation on 11/7/23 at 2:24 PM, identified that Resident #62 was in the television room wearing slipper socks and a green, foam waffle boot to his/her left foot. Although Resident #62 was noted to be wearing the green foam waffle boot, his/her left heel was resting on the wheelchair foot pedal. Observation of the heel area of the green foam boot failed to identify that the boot had off-loading properties such as a cut out which would relieve pressure off the pressure injury. Additionally, Resident #62's right heel lacked a heel boot and failed to be off-loaded from the wheelchair foot pedal. Interview with NA #8 on 11/7/23 at 2:28 PM identified she had not seen Resident #62 wearing shoes or heel boots recently. Review of a late entry nursing change in condition assessment note entered by LPN #1 on 11/1/23 at 2:44 PM indicating that a blister was present on the left heel and that s/he had mistaken the new blister to be the one that was a previously documented wound on the right heel. Interview with LPN #1 on 11/7/23 at 3:42 PM identified she was on duty on 10/26/23 on the 7:00 AM to 3:00 PM shift when the pressure ulcer to the left heel was identified. LPN #1 stated that she floated between units and was not initially aware that the left heel was a new skin impairment when it was brought to her attention. LPN #1 indicated that she believed the pressure ulcer was still the same pressure ulcer of the right heel (that had been noted to have been healed on 9/18/23). LPN #1 identified that the facility policy was to measure new pressure ulcers and notify the wound nurse, but she had not known the left heel was a new pressure ulcer. LPN #1 identified she was directed, by the DNS, on 11/1/23 to write a late entry nursing note. Review of the facility Skin Integrity and Wound Management policy dated 2/1/23 identified, in part, that a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal would be performed. The plan of care for the patient would be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff would continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Risk evaluations would be conducted quarterly and with a significant change in condition, and a complete wound evaluation with new in-house acquired wounds and with unanticipated decline in the wounds would be conducted. Pressure injury prevention would be implemented for identified, modifiable risk factors. Determination of appropriate support surfaces for the bed and chair would be made as well as the need for heel off-loading and revise the care plan as indicated. 48879

Based on observations, facility documentation, resident council minutes, facility policy, review of facility staffing hours, and interviews, the facility failed to adequately staff Nurse Aides (NA) throughout the facility resulting in resident care needs not being met. The findings include: 1. Resident #21 's diagnoses included dementia, heart disease, and communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and required supervision with transfers and extensive assistance with dressing and personal hygiene. The Resident Care Plan dated 9/1/22 identified Resident #21 required assistance with Activities of Daily Living. Interventions included providing staff assistance with personal hygiene. Observation on 11/6/23 at 3:10 PM, identified Resident #21 at the nursing station, with dark debris under 9/10 fingernails that were long, as well as long facial hair. Review of NA flow sheets (amount of care required) from 11/1/23 through 11/7/23 identified that Resident #21 had ranged from requiring supervision to being totally dependent on staff for personal hygiene. Observation on 11/7/23 at 11:00 AM, identified Resident #21 in attendance at an activity. Resident #21 was noted with dark debris under 9/10 fingernails and was noted with long facial hair. Interview and observation with NA #2 on 11/7/23 at 12:20 PM identified Resident #21 was probably last shaved on his/her shower day, 5 days prior. NA #2 indicated that if there weren't enough staff, then residents' fingernails and shaves did not get completed. Although NA #5 indicated that the facility required 5 staff on the unit to complete hygiene care and services, and had 5 staff present on 11/7/23, she indicated that 5 NA staff on the unit during the 7:00 AM to 3:00 PM shift did not happen often. Review of nursing notes and APRN/MD notes from 11/1/23 through 11/7/23 failed to identify that Resident #27 had been refusing assistance with Activities of Daily Living. 2. Resident #53's diagnoses included Alzheimer's disease, major depressive disorder and cognitive communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 was severely cognitively impaired and required the assistance of 1 staff with bed mobility and transfers. Observation on 11/1/23 at 12:55 PM identified Resident #53 with long, jagged nails with a dark substance beneath and the appearance of dried blood on his/her hands. Licensed Practical Nurse (LPN) #3 was notified of Resident #53's hand/nails and stated Resident #53 had a history of picking at the lesion to the top of his/her head and LPN #3 identified she would get a Nurse Aide (NA) to provide care to the resident. The Resident Care Plan dated 11/2/23 identified Resident #53 was at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing related to recent illness, fall, hospitalization resulting in fatigue, activity intolerance, confusion. Interventions included monitoring conditions that may contribute to ADL decline, monitor for decline in ADL function, and to provide resident with extensive assist of 1 for bed mobility, dressing, personal hygiene and bathing. Observation of Resident #53 on 11/7/23 at 9:35 AM identified dark brown debris beneath Resident #53's nails and his/her nails continued to be long and jagged. Interview with NA #9 on 11/7/23 at 10:37 AM identified that nail care, shaving, and weights are only completed when they are fully staffed. She stated if she sees long nails, she will go back to the resident when she's done with regular daily care, otherwise she will pass it on to the next shift. Additionally, NA #9 identified when the NA's are short staffed, they can have assignments up to 12 residents. Interview with NA #4 on 11/7/23 at 11:42 AM identified that she was not able to get work done the way she wants to due to short staffing but will always try to go back the same day and complete care when time permits. She stated that when the facility was not short staffed, she tried to catch up on care like nails and shaving whenever she could. 3. Review of Resident Council minutes dated 9/21/23 identified residents remain in bed until lunch due to the lack of staff, resident beds are not made or changed after residents get up, and staff can be heard discussing concerns regarding staffing issues at the facility. Interview with DNS on 11/8/23 at 10:30 AM indicated that she was aware of the staffing issue and that this was a common Resident Council complaint. The DNS identified that the facility lacked a Human Resources staff member and that this had contributed to the lack of hiring new staff. Additionally, the DNS indicated that the facility corporate office did not allow the use of agency to replace the missing staff due to the associated high cost. The DNS stated that current staff does what they can to assist on the units. 4. Resident #527's was admitted with diagnoses that included Down Syndrome, Alzheimer's Disease, and diabetes mellitus. The admission nursing assessment dated [DATE] identified that Resident #527 was admitted due to psychiatric/behavior/mental health issues and for therapy following a fall. Additionally, Resident #527 had agitation/restlessness and was hyperactive. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #527 had long and short term memory problems and required extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 staff with toileting. The Resident Care Plan dated 10/25/23 identified Resident #527 with behaviors including resistance to care, removal of clothing in public, throwing items on the floor, attempts to self-transfer, and self-ambulate, and using a wheelchair to set him/herself on the floor. Interventions included allowing time to express feelings, provide empathy encouragement and reassurance, provide a consistent trusted caregiver, and provide a structured daily routine when possible. Review of APRN notes dated 10/16/23 through 11/6/23 directed staff to remain with the resident and keep the resident in his/her bed or chair for safety. Review of the Medication Administration Record and the Treatment Administration Records from 10/13/23 through 11/7/23 failed to document that staff had remained with Resident #527. Review of nurse's notes dated 10/14/23 through 11/7/23 identified the following: A. On 10/14/23 at 9:42 PM Resident #527 was found on the floor after independently transferring out of bed. B. On 10/30/23 at 8:37 PM Resident #527 flipped a chair over, causing it to land on Resident #527's leg/foot, and that s/he was bleeding from the left great toe. C. On 10/31/23 at 11:35 PM Identified that Resident #527 was frequently standing unassisted and had pulled the fire alarm. Review of the Reportable Event dated 11/7/23 at 4:30 PM identified staff to resident abuse without injury. Resident #527 was found to be restrained to his/her wheelchair by a bed sheet that was tied around his/her waist. Review of facility staffing dated 11/3/23 identified that the facility had 2 NAs assigned to work the 3:00 PM to 11:00 PM shift, 1 NA assigned to work 4:00 PM to 11:00 PM shift, and 2 LPNs were assigned to work from 3:00 PM to 11:00 PM. The facility census on Resident #527's unit was noted to be 35 residents. Interview with the Administrator and the corporate Clinical Specialist, RN #6, on 11/08/23 at 2:43 PM identified that upon investigation of the incident, NA #12 admitted to tying Resident #527 to his/her wheelchair. The Administrator stated that NA #12 indicated the shift had been hectic, Resident #527 had been disrobing, throwing his/her clothes on the floor, and was restless. The Administrator indicated staffing that evening consisted of 1 NA who came in at 3:00 PM, 1 NA who came in at 4:00 PM, and 1 NA came in at 5:00 PM. In the interim, managerial staff covered the floor until there were 2 or 3 NA's present. Additionally, the charge nurse, LPN #6, had also been assisting with resident care. The Administrator identified that normal staffing for that unit depended on acuity and there should have been 3 or 4 NAs to care for the 35 residents. Interview and review of the facility statement dated 11/8/23 with LPN #6, on 11/9/23 at 12:56 PM indicated that Resident #527 had been shirtless and that she untied Resident #527 from the wheelchair. LPN #6 stated that she would usually bring Resident #527 with her during medication pass to watch him/her and keep him/her from falling because the facility was always short of help. LPN #6 indicated that NA #14 had been at the facility but had left early according to another NA, at an unknown time and without notifying her. LPN #6 indicated that she had informed the DNS that Resident #527 was not appropriate for the facility/environment and the DNS informed her that the resident's former living arrangements were not currently available. LPN #6 identified that the unit should have 5 NA to adequately care for residents on the unit but were lucky to get 3. LPN #6 denied seeing any managerial staff assisting the staff on 11/3/23. Interview and review of the facility statement dated 11/8/23 with NA #12 on 11/9/23 at 1:31 PM identified that the facility had been short-staffed for the past 3 months, the unit often had only 2 NAs for 45 residents on the 3:00 PM to 11:00 PM shift, and that she had complained about staffing to the DNS and Administrator. Additionally, she had informed the Administrator, and been informed by both the Administrator and LPN #7, that Resident #527 needed 1 to 1 supervision due to his/her behaviors. NA #12 had witnessed the Administrator see Resident #527 remove his/her clothing, but no additional staff was ever provided. NA #12 indicated she felt Resident #527 required a belt and/or a special chair but failed to voice this to any staff members. According to NA #12, on 11/3/23, LPN #6, stated that she had things to do, could not watch Resident #527 all the time, and was done with Resident #527. NA#12 identified, at approximately 3:45 PM, she was the only NA on the unit, and saw Resident #527 removing his/her clothing. She took Resident #527 to the bathroom, completed incontinent care, and tied a sheet around his/her waist to restrain Resident #527. NA #12 identified that she intended to inform LPN #6 she was restraining Resident #527 but could not locate her. NA #12 said she did not know what else to do as call lights were ringing and other residents were calling for water and no other staff were present. NA #12 felt in order to keep Resident #527's from falling and from grabbing items that might cause an injury, she placed a sheet around his/her waist. NA #12 noted that Resident #527 was known to throw paper off counters, had pulled the fire alarm, and had grabbed the fire extinguisher. NA #12 identified that she could not possibly watch Resident #527 and care for her other 17 residents at the same time. NA #12 indicated that NA #13 did not arrive at the facility until 4:00 PM and that she had not seen any managerial staff on the unit. NA #12 identified that she knew placing the resident in a restraint was bad, but she didn't want Resident #527 to break a bone. NA #12 identified that when she saw Resident #527 with the SLP, the belt was off, and she was thankful that someone was there to watch him/her. Interview and review of the facility statement dated 11/7/23 with the DNS on 11/13/23 at 2:30 PM identified Resident #527 was as close to a 1 to 1 as you get, adding, on 11/3/23, there was not sufficient staff to watch Resident #527 due to a call out as well as a NA who did not show up. The DNS identified that she and the Administrator had stayed until 4:45 PM to help staff. Although the DNS indicated that no staff had ever come to her to complain about their assignment, she could see that Resident #527 had many behaviors. These behaviors included disrobing, throwing objects, trying to ambulate, or trying to get onto the floor. The DNS identified that Resident #527, was discussed daily at morning meeting and staff were in agreement Resident #527 was not an appropriate placement for the facility due to his/her need for additional attention and lack of facility staff. The DNS indicated that she had not requested additional help from the Administrator for a 1 to 1 as the corporate office prohibited agency use and told the facility management to instead offer bonuses to current staff. The facility had previously used licensed staff to work as NAs but was told by corporate this was not in the budget. The DNS indicated that she had tried calling all his/her staff to fill the staff vacancies on 11/3/23 but had been unsuccessful. Interview and review of facility staffing with the Administrator on 11/13/23 at 3:32 PM identified the following staffing for 11/3/23: 1. NA #12 arrived at 3:14 PM and punched out at 11:09 PM. 2. NA #13's arrived at 4:00 PM and punched out at 11:08 PM. 3. NA #14 arrived at 3:00 PM and lacked further information except that she was unpaid. 4. LPN #6 arrived at the facility on 11/2/23 at 7:15 AM and left at 11:04 PM. 5. LPN #7 arrived at 3:30 PM and left at 11:45 PM. Re-interview with the DNS on 11/13/23 at 3:40 identified that although she had a statement denying knowledge of Resident #527's restraint and a text indicating NA #14 was at the facility, the DNS indicated that NA #14 was not actually there. Attempts to interview NA#13 and LPN #7 were unsuccessful. Review of the Staffing/Center Plan policy last revised 8/7/23 directed, Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week and will meet or exceed the staffing levels mandated by state and federal staffing requirements. Staffing levels are reviewed on an ongoing basis by Center staff to evaluate compliance and provide appropriate levels of care by qualified employees.

Based on observations, facility policy, facility documentation, and interviews for 2 of 2 resident units, for Resident #'s 28, 51, 61, 278, and 428, who were reviewed for receiving a nourishing snack when mealtimes exceeded 14 hours, the facility failed to provide adequate snacks. The findings include: Intermittent interviews on 10/31/23 between 10:30 AM and 2:00 PM and 11/2/23 between 12:00 PM and 2:00 PM with Resident's #28, 51, 61, 278, and 428 identified that the residents were receiving a small snack in the evening only upon request. The resident's reported examples of the snacks brought when requested were a cookie, cookie bar, apple sauce, or juice and they did not feel that this was an adequate and substantive snack. Interview and review of facility documentation with Dietary Supervisor #2 on 10/31/23 at 10:45 AM during the initial kitchen tour identified that meals were served at 7:30 AM, 11:30 AM, and 4:30 PM and that snacks were given in the evening hours and consist of small items. A 15-hour gap was noted between the dinner service at 4:30 PM and breakfast service at 7:30 AM. A Resident Council meeting was held on 11/2/23 at 1:30 PM, during which Resident #28 indicated continued concerns with the too early arrival time of dinner, and objected to the 15 hour gap between dinner and breakfast. An observation of the nourishment station on the Tuxis unit on 11/7/23 at 11: 00 AM failed to identify any available resident snacks. An interview with Dietary Aide (DA) #1 on 11/7/23 at 12:45 PM identified that nourishments are delivered to residents when facility staff reported that residents would like to have a snack. DA #1 identified that DA's are responsible for preparing and delivering the snacks to the unit. Interview with Director of Dietary on 11/08/23 at 10:43 AM, indicated that nourishment carts (cookies, peanut butter and jelly sandwiches, pudding, and fruit cups) were put into each unit kitchenette by evening staff. Interview with NA#2 on 11/8/23 at 10:50 AM indicated that it was very rare that the Dietary Department delivered a snack cart to the unit. NA #2 identified that if a resident requested a snack, NA's had to go to the kitchen themselves and obtain the snack. Further, NA #2 indicated that nursing units have not received a snack car, sometimes for weeks at a time. Although attempted, an interview with the Dietician could not be completed due to unavailability. Review of the Snack, Nourishments, Supplements, and Pantry Stock policy dated 5/1/23 directed, in part, that the evening snack is a planned as part of the menu and that established par levels for stock foods would be stored for use on the nursing units.

Based on observation, facility documentation, facility policy, and interviews, the facility failed to follow infection control practices on 1 of 2 units to provide a clean environment for Resident #53, and for the Infection Control Program, failed to ensure all required infection control policies and procedures were present in the Infection Control Manuals. The findings include: 1. Resident #53's diagnoses included Alzheimer's disease, cognitive communication deficit, and inflammatory polyarthropathy (arthritis affecting 5 or more joints). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 was severely cognitively impaired and required the assistance of 1 staff with bed mobility and transfers. The Resident Care Plan dated 11/2/23 identified Resident #53 was at risk for decreased ability to perform activities of daily living (ADLs) in bathing, grooming, personal hygiene, and dressing related to recent illness, fall, hospitalization resulting in fatigue, activity intolerance, confusion. Interventions included to monitor conditions that may contribute to ADL decline, monitor for decline in ADL function, provide resident with extensive assist of 1 for bed mobility, dressing, personal hygiene and bathing. Observation on 10/31/23 at 11:12 AM, identified Resident #53's room with a full trash can on the bedside chair by the door, as well as soiled linens and incontinent pads on the floor. Interview with Housekeeper #1 on 10/31/23 at 11:15 AM identified the trash can and linens/incontinent pads should not be there. She stated from her experience on this unit, the residents in that room were not capable of picking up and putting the trash can on the chair. She picked up a clean brief that was sitting next to the chair and stated her guess was that it was a staff member that left the room in disarray. She indicated that the staff often leave rooms messy and that she does the best she can but that she has 40 rooms to clean on her shift. 2. During a review of the facility infection control program, facility policy manuals, the facility lacked the required policies for: Undiagnosed respiratory illness (requiring containment) and Plan for early detection, management of a potentially infectious, symptomatic resident requiring lab testing or implementation of appropriate Transmission Based Precautions/Personal Protective Equipment (TBP/PPE). Interview on 11/8/23 at 11:05 AM with Registered Nurse (RN) #3 indicated she was unable to locate the policies or state what guidance the facility followed in regard to the policies that were not located within the infection control policy manuals. RN #3 indicated she would follow up with the Director of Nursing Services (DNS) to see if they were able to locate them. Interview on 11/8/23 at 2:09 PM with RN #3 identified she nor the DNS had not been able to find the missing policies, and that they were not aware of all of the infection control policies required. The Infection Control Outcome and Process Surveillance and Reporting policy last revised 2/1/23, directed, in part, that the Infection Preventionist will conduct regular outcome surveillance consisting of collecting/documenting data to standard, written definitions of infection. They will also conduct process surveillance to review practices directly related to resident care to include monitoring of compliance with Transmission Based Precautions, proper hand hygiene, the use and disposal of gloves, and observation of the environment. This is done to detect possible communicable diseases or infections, plan control activities before communicable diseases or infections can spread to others, and identify and manage potential outbreaks of disease, as well as identify whether the practices comply with established prevention and control procedures and policies based on recognized standards. Although a policy was requested on Infection Control practices within the facility, one was not provided.

Based on review of facility Resident Council meeting documentation, interviews, and facility policy, the facility failed to adequately respond to resident grievances. The findings include: 1. Review of Resident Council minutes dated 9/21/23 identified the following concerns: A. The supper meal was arriving too early, at approximately 4:10 PM, and residents were not receiving their alternative meal choices. Review of the Resident Council minutes identified that cooks were made aware of the concern. B. Residents remained in bed until lunch due to the lack of staff, resident beds are not made or changed after residents get up, and staff can be heard discussing concerns regarding staffing issues at the facility. C. The 3:00 PM to 11:00 PM staff were heard loudly discussing residents' personal information in the hallways, using inappropriate language, and nurses were heard yelling down the hall instead of going to directly to speak with staff. 2. Review of the Resident Council minutes dated 10/19/23 identified the following: A. Residents were informed by the Dietary Department of a new dinner delivery time, 4:30 PM, but residents still objected to the new time, and had requested a later dinner delivery. B. Residents continued to express concerns with the 3:00 PM to 11:00 PM staff being loud in the hallways and at the nurse's station. Review of the Resident Council minutes identified that Nursing was aware of the concern. During the Resident Council meeting on 11/2/23 at 1:30 PM, Resident #28 indicated continued concerns with the early arrival time of dinner and that alternative meals were still not being provided as requested. Additionally, members of the Resident Council collectively expressed concerns that staff continue to speak loudly at night yelling information down the hall. Interview and review of facility documentation with the Director of Dietary on 11/2/23 at 2:15 PM identified that dinner was being provided to residents at 4:30 PM, despite the Resident Council meeting minute objections. Interview with DNS on 11/8/23 at 10:30 AM indicated that she was aware of the staffing issue and that this was a common Resident Council complaint. The DNS identified that the facility lacked a Human Resources staff member and that this had contributed to the lack of hiring new staff. Additionally, the DNS indicated that the facility corporate office did not allow the use of agency to replace the missing staff due to the associated high cost. The DNS stated that current staff does what they can to assist on the units. The DNS indicated that she had not been made aware of Resident Council concerns for the early arrival of dinner. Interview with the Director of Dietary on 11/08/23 at 10:43 AM, identified he was aware of the concern that dinner was being sent to the units too early. The Director of Dietary stated that his staff had been educated not to serve dinner so early, but if a manager was not present in the building, the problem continued. Review of the facility Grievance policy identified that service location leadership would investigate, document, and follow up on all concerns and grievances. Additionally, the facility would receive prompt receipt and resolution of grievances/concerns.

Based on clinical record review, review of facility documentation, and interviews for one of three residents reviewed for accidents, (Resident#1), the facility failed to ensure that the resident was positioned properly prior to repositioning in a customized wheel chair, and failed to ensure that the facility staff assisted a vendor in repositioning a resident for an X-ray, resulting in an injury. The findings include: 1) Resident #1's diagnoses included Congestive Heart Failure, and osteoporosis. a) An admission Occupational Therapy (OT) assessment dated [DATE] identified Resident #1 was unable to sustain sitting or standing tolerance, static sitting was poor requiring maximum abdominal and upper extremity support, and the resident's dynamic sitting balance during activities of daily living was poor. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assist of two staff for transfers, extensive assistance of one staff member for bed mobility was totally dependent for toileting, and personal hygiene. A resident care plan (RCP) identified dated 10/6/21 that Resident #1 required substantial assistance for repositioning. A nurse's note dated 11/10/21 at 9:55 PM identified Resident #1 slid out of wheelchair while a Nurse Aid (NA) was adjusting the position in the Customized Wheelchair (CWC), and impacted on the right side of h/her body against the bedframe area. Resident #1's right arm was examined by a Register Nurse and found to be misaligned, the resident was sent to the emergency department for evaluation. A reportable event dated 11/10/21 at 8:45 PM identified Resident #1 fell forward out of the customized wheelchair and onto the floor after NA #1 placed the wheelchair from a reclined position to an upright position. The reportable event further identified that NA#1 witnessed Resident #1 fall forward out of the CWC and NA #1 attempted to prevent Resident #1 from hitting his/her head on the footboard of the bed, and placed her hands on Resident #1's right arm to lower him/her to the floor when NA#1 heard a click. An X-ray identified that Resident #1 sustained a right proximal humeral fracture. Review of Resident #1's hospital paperwork dated 11/10/21 identified that the resident had a Right proximal Humeral head fracture and the resident would be treated medically with a cuff and collar sling to the right extremity. An Advanced Practice Registered Nurse (APRN) note dated 11/12/21 at 1:05 P.M. identified Resident #1 had a displaced right humeral fracture, a cuff and collar sling placed was in place to the right arm, and the resident was non-weight bearing to right upper extremity. An interdisciplinary therapy screen assessment dated [DATE] identified that Resident #1's customized wheelchair (CWC) tilt in space mechanism was evaluated for possible cause of Resident #1 falling out of the CWC. The note further identified the facility's therapy department staff examined Resident #1's CWC, recreated all possible scenarios of positions, and attempted multiple times to go from the tilted position to an upright position and on all attempts, there was no evidence or possibility that the resident could have been propelled out of the CWC. The note further identified that the therapist went from a tilted position to an upright position with Resident #1 with no evidence of Resident #1 being propelled forward out of the CWC. The note identified that the CWC mechanism of the tilt in space going from tilt to upright is not broken and was working appropriately. Interview with Director of Therapy on 5/16/22 at 2:05 PM identified that Resident #1 was not capable of repositioning h/herself. The therapy director identified that Resident #1 was unable to use the CWC's pelvic positioning device to the keep hips all the way back in the CWC because it was not a good option for Resident #1 secondary to the resident' frailty but one or two person staff assistance for repositioning was indicated. The therapy director identified that staff should check positioning of the resident to ensure the resident is seated all the way back in the CWC prior to adjusting the CWC from reclining to sitting position to ensure safety. The clinical record failed to identify any information regarding the CWC or its features prior to 11/10/21 (please cross reference F 825). Interview with Occupational Therapist (OT) #1 on 5/17/22 at 2:39 PM identified that Resident #1 had contractures from the waist down, and poor trunk control. Resident #1 was transferred from the bed to the CWC with the use of a Hoyer lift, and the Hoyer pad could be used to help readjust Resident #1 while in the CWC if needed. OT#1 identified that she never saw Resident #1 slide out of CWC, move around or wiggle while in the CWC, if Resident #1 needed to be repositioned then only minor adjustments would be needed requiring only one staff needed to make those adjustments. Interview with National seating and Mobility Sales Professional on 5/19/22 at 10:20 A.M. identified that he is certified in the use of Resident #1's customized wheelchair (CWC). The Sales Professional further identified that adjusting the CWC positioning requires two hands pressing down the levers on the back of the chair and pushing forward to achieve the different angles of tilting from a 55 degree angle to a 90 degree angle. The sales professional identified that anyone making position adjustments to the CWC should not go to fast or be too aggressive while making the position change, as this could cause the CWC to lift up off the ground and could cause the person seated in the CWC to fall forward or out of the chair if the CWC's pelvic positioning belt is not utilized, especially if the resident is small, frail, with poor trunk control. The Sales Professional further identified that the expectation would be for staff to ensure that the resident correctly positioned in the CWC, ensuring that the residents buttocks all the way back in the wheelchair, and to have two staff members present, one staff member to press down the levers to reposition the tilt, and the other staff member to ensure safety while repositioning the resident. Interview with Nursing Assistant (NA) #1 on 5/19/22 at 1:10 P.M. identified that she was assisting Resident #1 with care, she repositioned Resident #1's CWC from the reclining position to the upright position when she saw that Resident #1 was falling forward out of the CWC. NA#1 identified that she reached for Resident #1's arm to prevent Resident #1 from falling on his/her face, and she heard a crack when the resident was being lowered to the floor. NA#1 identified that Resident #1 was on a Hoyer pad while in the CWC, and she did not adjust the position the CWC abruptly or in a fast manner, however, she did not check Resident #1's buttocks was all the way back in the CWC prior to repositioning the chair to the upright position. Interview with Advanced Practice Registered Nurse (APRN) #1 on 5/17/22 at 2:00 PM identified that Resident #1 had osteopenia, had long term blood thinner use, history of multiple fractures making him/her more susceptible to fractures, and NA#1 reaching for Resident#1's arm while falling could cause the right arm humeral fracture. Interview with the DNS on 5/19/22 at 10:58 A.M. identified that Resident #1 had poor trunk control, was very contracted in the lower extremities, and was likely tired after being in the CWC during the day prior to falling forward out of the CWC. The DNS further identified that the staff member should have ensured Resident #1 was correctly positioned in the CWC prior to bringing the CWC to the upright position. The DNS further identified that after the incident the new intervention was added to Resident #1 care plan for assist of two for care and mobility. The facility failed to ensure that the resident was properly positioned, with the resident's buttocks all the way back, prior to placing the CWC from the reclined position to the upright position. b)The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 was severely cognitively impaired and required extensive assist of two staff for transfers, bed mobility, toileting, and personal hygiene. A resident care plan dated 4/15/22 identified that that Resident #1 had limited mobility and required substantial assistance to move from sitting on side of bed to lying flat on the bed. A nurse's note dated 4/19/22 at 1:30 P.M. identified that the resident had a change in condition for respiratory infection and cough. The Advanced Practice Registered Nurse was contacted and a STAT chest X-ray, oxygen, nebulizer treatments, and Prednisone (a steroid) were ordered. An Advanced Practice Registered Nurse (APRN) note dated 4/20/22 at 12:00 AM identified that the resident was seen for pneumonia and left breast swelling. The resident was noted to have new swelling to h/her left breast with scattered ecchymosis present, the resident has not suffered any recent falls or trauma, the Chest X-ray taken on 4/19/22 was negative for any acute fracture or dislocation. A Reportable Event (RE) dated 4/20/22 at 10:00 A.M. identified Resident #1 was found with bruising and swelling on the left breast, chest area, and under the left arm when care was being given on 4/20/22, the bruising was immediately reported to the nurse. The RE investigation identified that Resident#1 had no bruising or swelling noted on any of the previous shifts on 4/19/22. The RE investigation and summary identified that Resident #1 was on a high dose anticoagulant and had a chest x-ray on 4/19/22 during the evening (3:00 PM to 11:00 PM) shift. An untimed APRN note dated 4/21/22 at 11:35 A.M. identified Resident #1 with worsening swelling to the suspected hematoma with new orders to place Lovenox (an anticoagulant) on hold for three days, a STAT order for hemoglobin and hematocrit, ice and elevation as needed and continuation of monitoring the area. A nurses note dated 4/22/22 at 4:02 A.M. identified Resident #1 was had head of bed elevated, easily aroused, and stating yes when asked about pain to left breast area, the resident was medicated with good effect. The note further identified Resident#1 left breast area had noted edema with bluish purple discoloration on top of breast site, upper chest, and under the arm pit measuring 8 cm x 23 cm. A nurse's note dated 4/23/22 at 5:50 A.M. identified Resident #1 was alert and verbal, resting with head of bed elevated, appeared comfortable and without distress. The note further identified occasional congested cough with antibiotics administered to treat pneumonia. The note identified Resident #1's left chest area swelling with ecchymosis persists, but slightly decreased in size to 8 cm x 20 cm. A SBAR communication form dated 4/24/22 10:00 A.M. identified Resident #1 with worsening condition including oxygen saturation at 88% ( normal oxygen saturations are between 90 and 100 %) with labored breathing and non-productive cough. The communication form further identified Resident#1 had a large hardened discolored area with blistering to the left side of chest and breast. The communication note identified that the APRN ordered Resident#1 to be transferred to emergency room due to increased respiratory distress, a positive COVID-19 test, and decreased oxygen levels. An emergency room report dated 4/24/22 identified Resident #1 was transferred to the hospital for an evaluation of hemorrhage and diagnosis of pneumonia and positive COVID-19. The report further identified that upon arrival to the emergency room Resident#1 was on five (5) liters of oxygen and oxygen saturation of 96%, initial labs identified Resident#1 white blood cell count was 18.5, hemoglobin 4.7 (normal hemoglobin levels are between 12 and 15 grams per deciliter) and received 2 units of red blood cells and admitted to the hospital for further management. A hospital physician's note dated 4/25/22 at 7:30 A.M. identified that Resident#1 had admitted with polytrauma including a sternal fracture and large left wall hematoma in the setting of COVID-19, pneumonia, and anemia, requiring blood transfusion. The mechanism of injury was unknown, with recommendations to admit to a medical step-down unit, no acute surgical intervention for sternal fracture or chest wall hematoma, the resident will require supportive care, transfusion of blood for anemia, and apply device for light compression around the chest to help with hematoma swelling if tolerated. An email dated 4/25/22 at 12:37 P.M. from the DNS to the X-ray account executive identified that the DNS was trying to get in touch with the X-Ray technician who performed a chest x-ray on Resident#1 on 4/19/22 and the next day Resident#1 had significant bruising to his/her left chest/axilla area. An email dated 4/26/22 at 4:17 P.M. from the X-ray account executive to the DNS identified the X-ray technician's written statement describing that he performed a chest X-ray per physician order on Resident#1 on 4/19/22. The statement further identified that Resident#1 was asked to lean forward, and he placed the x-ray plate behind his/her back. The statement identified that he took the x-ray and asked R#1 to lean forward again, and he removed the plate and left Resident#1's room without incident. An email dated 4/27/22 at 9:37 A.M. from the DNS to the X-ray account executive identified that the Resident#1 was asked to lean forward and was cooperative with the request, however, the DNS identified that Resident #1 was unable to lean forward on his/her own. The email further identified that the DNS is requesting the X-Ray technician be educated to ask facility staff for assistance if the resident/patient is unable to reposition indecently upon request. A RE summary dated 4/28/22 concluded Resident#1's injury was a result of the X-ray tech independently repositioning Resident #1 when the X-ray plate was placed underneath Resident#1, causing the injury discovered on 4/20/22. The RE summary further identified that the facility's investigation determined that staff members from all three shifts who cared for Resident #1 on 4/19/22 identified that Resident #1 had no bruising or swelling to the left chest/axilla area prior to the discovery of the bruising on 4/20/22. The RE summary identified that on 4/20/22, the day after the x-ray, Resident #1's had bruising and swelling to the left chest/axilla region which developed into a large hematoma that was exacerbated by Resident #1 taking 80 milligrams of Lovenox daily. An interview with Nursing Assistant (NA) #2 on 5/19/22 at 3:10 P.M. identified that on 4/19/22 at approximately 4:30 P.M., she was asked, along with another NA on the unit by Licensed Practical Nurse (LPN) #1 to transfer Resident #1 from the CWC to his/her bed for an X-ray to be taken. NA#2 further identified that Resident #1 transfers from the CWC to the bed using a Hoyer Lift, which requires two staff members, and was done without incidence. NA#2 identified that once the transfer was completed and Resident #1 was positioned in the bed, she left the room without assisting the X-ray technician with the chest X-ray. NA#2 identified that unless the X-ray technician asks for assistance, she would leave the room and take care of other residents. NA#2 further identified the X-ray technician did not ask the aides to assist with Resident #1's re positioning for the X-ray to be taken. Although multiple attempts were made to interview LPN#1 they were unsuccessful. An interview with the X-ray technician on 5/19/22 at 2:42 P.M. identified that he was unable to recall that event the X-ray taken on 4/19/22 for Resident #1, as he takes as many as twenty X-rays per day at multiple facilities. The X-ray technician further identified that if the resident needs to be placed back into bed for the chest x-ray to be taken, then the staff will do the transfer and if further assistance is needed, for instance if a resident is combative, he would ask the aides to stay and assist with the resident. The X-ray technician identified that although he was unable recall the resident, if the resident is unable to independently reposition themselves, was small in size and cooperative, he would typically reposition the resident himself. Interview with the DNS on 4/29/22 at 9:10 A.M. identified that on 4/19/22 Resident #1 was moved from his/her CWC via Hoyer left by two nursing assistants directed by LPN#1 so that a chest X -ray could be taken. The DNS further identified that during her investigation she obtained a written statement from the X-ray technician stating Resident #1 was able to lean forward after being instructed to do so, an x-ray plate was placed behind his/her back, and when the x-ray was complete, the X-ray technician asked Resident #1 to move forward again, and the X-ray technician removed the x-ray plate. The DNS further identified that the X-ray technician wrote that Resident #1 was cooperative with his request to reposition. The DNS identified that this would not have been possible as Resident #1 was unable to position him/herself at all and was completely dependent on staff for mobility. The DNS further identified that the x-ray technician did not ask staff for assistance with Resident #1 during or after the chest x-ray was taken, and would expect the X-ray technician to ask for assistance if needed. A subsequent interview with the DNS on 5/19/22 at 3:30 P.M. identified that the expectation for staff members to assist the X-ray technician if the technician should ask the staff for the assistance they need to perform a service for the resident. The DNS further identified after she completed her investigation for the injury on 4/19/22 it was concluded that injury was secondary to the X-ray technician not asking for assistance to reposition Resident #1. The X-ray technician used to much pressure and force to move Resident #1 onto his/her side to then place the x-ray plate behind Resident #1's back and then reposition Resident #1 onto the x-ray plate, and repeat this process for removing the X-ray plate, the X-ray technician may not have realized how fragile and prone to bleeding that Resident #1 was. The DNS further identified that when she assessed Resident #1's injury on 4/20/22 the bruising and swelling originated from the left axilla and radiated toward the left chest. The DNS identified that she contacted the agency that the X-ray technician works for and asked that he be educated to ask staff to assist with all transfers and repositioning if the resident is unable to do it independently. Interview with APRN #1 on 5/17/22 at 2:30 PM identified that was not aware that the resident was diagnosed with a sternal fracture at the hospital. The APRN further identified that although the resident had a diagnosis of osteoporosis, she did not think that the resident could have sustained a sternal fracture from being repositioned, and that it would have been caused by some type of trauma, for example something accidentally being dropped on the resident. Further interview with the Director of Nurses on 6/9/22 at 3:00 PM identified that the hospital had not reported to the facility that the resident had a sternal fracture, so the facility did not investigate the incident any further. The facility identified that they did not have a policy regarding vendors completing diagnostic procedures on residents, however, subsequent to the incident the facility educated the X-ray Company to ask for assistance if the resident is unable to position themselves independently.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents reviewed for ADL decline (R#9), the facility failed to identify a decline in transfer and ambulation ability and provide treatment to attempt to restore functional abilities. The findings include: Resident #9's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #9 had no cognitive impairment and required supervision and set up assistance with ambulation. The care plan dated 8/2/16 identified at risk for falls related to impaired mobility, [MEDICAL CONDITION] drug use, non-compliance with requesting assistance with ambulation and transfers. Interventions included refer to rehabilitation for bed to wheelchair and wheelchair to bed transfers. Review of the Reportable Event dated 8/1/16 identified that the resident was found sitting on the floor in front of his/her wheelchair and that he/she had attempted to sit in the wheelchair and missed the seat. PT referral done. A bruise measuring 2.5 cm x 2.5 cm was noted to the right elbow. Review of Reportable Events for falls identified that the resident had fallen on 2/6/16 at 12:30 PM, witnessed; 2/11/16 at 4:45 AM unwitnessed; 3/18/16 at 5 PM unwitnessed and with complaints of pain to the left side of neck, shoulder and hip (x-ray negative), 8/1/16 at 10 PM unwitnessed and with a bruise 2.5 cm x 2.5 cm to the right elbow; 9/30/16 unwitnessed bump to the back of the head, bruise to the right knee and complaints of hip pain with orders for neurological checks/right hip x-ray (x-ray negative), 10/13/16 at 11:45 AM unwitnessed, 12/17/16 at 11 AM unwitnessed, 2/12/17 at 10:15 PM unwitnessed and with complaints of slight discomfort in the left knee and on 2/24/17 at 2:30 PM unwitnessed (9 falls in 12 months). Review of the NA flowsheets in March, 2017 identified that the resident had been ambulated for 6 out of 25 opportunities, in February, 2017 for 12 out of 84 opportunities and in January, 2017 for 42 out of 93 opportunities. Interview with NA #1 on 3/9/17 at 10:16 AM identified that he/she was the primary NA for Resident #9 and that the resident was being ambulated by him/her. When asked if NA #1 would be ambulating the resident on this day, he/she identified that the resident had refused to ambulate, at that time, but he/she could re-approach later in the afternoon. Review of facility documentation and interview with PT#1 on 3/9/17 at 11 AM identified that he/she could not find any rehabilitation screen requests following the fall on 8/1/16. PT#1 identified that an annual screen had been performed in July of 2016 but that, according to the staff, the resident had no decline, and he/she was never picked up again until he/she was seen on 9/2/16. PT#1 identified that the Rehabilitation Department had completed an Occupational Therapy evaluation dated 9/2/16, but that the resident was referred for a right upper extremity impairment of the shoulder/wrist grip and that, although the resident was seen until 10/1/16, transfers were never addressed. The resident was previously last seen for rehabilitation from 7/2/15 through 7/30/15 and on discharge from therapy was noted to required the assistance of one staff for transfers and was ambulating 100 feet. PT #1 was not aware of the resident only ambulating intermittently with extensive assistance. Review of the facility NA documentation with PT#1 identified that PT#1 felt there was a decline in the resident's ambulation ability and that he/she would have to further evaluate the resident. Review of rehabilitation evaluation performed subsequent to surveyor inquiry on 3/9/17 identified that due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for decreased participation with functional tasks, falls, further decline in function and increased dependency upon caregivers. Reason for skilled services: patient requires skilled PT services to evaluate the need for assistive device, increase functional activity tolerance, maximize safety awareness and improve dynamic balance in order to enhance patient's quality of life by improving ability to decrease level of assistance from caregivers, increase participation with functional daily activities and perform functional mobility with reduced risk of falls. It was noted that the reason for the referral was a decline in functional ambulation, decline in transfers, history of falls and that the patient had a recent fall without injury attempting to self transfer. Transfers were noted to require moderate assistance with a prior level of function of minimal assistance and that the resident was only able to ambulate 1 to 5 feet on a level surface (was 100 feet prior). Subsequent to the initial evaluation, the resident was picked up Physical Therapy Services for a frequency of 5 times per week for a duration of 30 weeks and a certification period from 3/9/17 through 4/7/17.

Based on clinical record review, review of reportable event and investigation and interviews for one of four sampled residents reviewed for accidents/injuries (R#72), the facility failed to ensure that staff transferred and moved the resident appropriately to prevent injuries. The findings include: Resident #73's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identfied the resident was severely cogntively impaired, had no problem behaviors, required the extensive assistance of one person for bed mobility and transfers, and had impaired range of motion of one side. A nursing assessment dated [DATE] noted the right upper extremity had decreased range of motion and the resident was guarding the right arm but able to straighten arm on command. The care plan dated 12/31/16 noted a risk for falls. Interventions included assist of 2 with transfers and mobility as indicated; staff educated on transfers. A skin check on 2/15/17 was negative. A reportable event dated 2/20/17 at 2:45 PM identified that the resident was observed with swelling and bruising on the right posterior upper arm and right shoulder with tenderness. The resident was noted grimacing and moaning. The physician directed transfer to the emergency department for assessment. The hospital record dated 2/20/17 identified that resident was evaluated for right shoulder to elbow bruising, swelling and pain. X-rays were negative. The report noted that the resident was admitted for observation as son concerned about abuse/neglect and family was not notified of arm bruising. The resident was assessed with [REDACTED]. Elbow and upper arm swelling present. Also noted was yellow ecchymosis of the right elbow and purple ecchymosis right mid humerus to posterior shoulder. Review of the facility investigation noted that nurse aides had been transferring the resident by picking him/her up under the arms and by the pants into and out of bed. NA# 3, who had transferred the resident into bed on 3-11 PM shift on 2/19/17, documented in a statement that he/she transferred the resident without assistance. Also noted was that NA# 4 who cared for the resident on the 11-7 shift prior to finding the bruising and swelling on 2/20/17, held the resident over by him/herself with one hand on the resident's shoulder while providing incontinent care. The NA care plan directed bed mobility and transfers with the extensive assistance of 2+ person; may use Hoyer lift prn for fatigue. Review of the resident's annual therapy screens for 2014, 2015, and 2016 noted that the resident had remained the same status since 2014, when it was noted that a fall had occurred when one NA tried to transfer the resident alone. Staff were re-educated at that point that the resident required 2 staff for all transfers. There were no other physical or occupational therapy evaluations done in the previous year to indicate that the resident could be transferred with one staff. Interview with DNS on 03/07/2017 at 9:37:13 AM noted that based on the investigation, staff were re-educated on safe transfers and handling of residents. The DNS indicated that the resident did not return to the facility at family request.

Based on review of the clinical record, review of facility documentation, observation, and interview for one of two resident's reviewed for pressure ulcers (R#3), the facility failed to implement interventions including offloading of heels and/or heel protectors to prevent the development of an unstageable pressure ulcer. The findings include: Resident # 3's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had impaired cognition, required extensive assistance with ADL's including bed mobility, and had no pressure ulcers. The RCP dated 11/12/15 identified a risk for skin breakdown related to incontinence and limited mobility. Interventions directed the staff to reposition 4 times a shift, float heels while in bed and heel boots if resident allows. Nurse ' s notes dated 11/24/15 at 2:23 PM identified a new onset pressure ulcer located on the right inner heel that measured 3 cm. The physician was notified and a new order was obtained for soft booties to foot at all times and elevate heels while in bed. An APRN note dated 11/25/15 identified an intact DTI on the right heel that measured 3.5 cm by 2.5 cm. An off loading boot was donned and the staff was directed to continue hydraguard lotion for treatment. The resident denied associated pain at this time. On 12/16/15 the wound measured 3.8 cm by 2.9 cm, intact and slightly larger. An APRN note dated 1/11/16 identified that the wound was now open with stable-eschar in the center and a scant amount of serosanguineous drainage. The resident now complained of pain and APAP #3 was ordered for pain control. On 1/20/16 the ulcer measured 4.0 cm by 2.8 cm and the development of a blister was noted. On 1/27/16 the unstageable ulcer measured 5 cm by 3 cm with stable eschar that covered 75% of the wound and 25% open area. The resident ' s pain continued and the staff was directed to medicate the resident prior to conducting the treatment. An APRN note dated 2/3/16 identified the ulcer with 80% eschar and Santyl was ordered for debridement. Observation of the wound treatment on 2/4/16 at 12:15 PM with RN#4 identified the right heel with a large amount of black eschar present in the center of the ulcer. Although medicated prior to the treatment, the resident winced in pain as the treatment was conducted. Interview and review of the clinical record on 2/2/16 at 10:30 AM with LPN# 2 failed to provide documentation that the resident ' s heels were off loaded prior to the development of the ulcer as per the care plan. LPN #2 indicated that although pillows were sometimes used to elevate the heels, the resident would often refuse and kick the pillows off the bed. Additionally, the resident would often refuse to get out of bed. The Behavior Tracking Form for November 2015 identified that although the resident was monitored for hitting and scratching behaviors, resistance to care and/or getting out of bed were not identified as problem behaviors and not documented. Review of the clinical record on 2/4/16 at 12:30 PM with RN#1 identified the RCP failed to address the resident refusal to elevate her/his heels in bed and/or lacked alternative interventions to protect the resident ' s heels, and/or the NA Care Card failed to direct the NA to off load the resident ' s heels while in bed.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who was reviewed for an allegation of staff to resident abuse, the facility failed to ensure the resident was free from verbal abuse. The findings include: Resident #1's [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] identified Resident #1 was alert and oriented, required extensive assistance with bed mobility and some assistance with activities of daily living, was continent and utilized the bathroom and/or a urinal. The Reportable Event Form dated 8/8/15 at 3:00 PM identified Resident #1 reported that an 11PM-7AM shift nurse aide told him/her that She didn't have time to keep assisting him/her. The nurse aide's comment to Resident #1 was I'll put a diaper on you and you can pee in it and she had to get some sleep. The investigation identified that when conducting resident rounds and throughout the 11-7AM shift, the Nurse Aide (NA) was heard by the Registered Nurse (RN) Supervisor swearing and making derogatory comments in front of and towards Resident #1. In an interview with Resident #1 conducted by the administrative staff on 8/11/15 at 4:30 PM Resident #1 identified he/she had rang the call bell several times because he/she was having trouble urinating. Resident #1 indicated that the nurse aide came into the room and stated to him/her what do you want, why do you keep ringing, some of us need to get some sleep. The nurse aide put a brief on Resident #1 and stated that it was there so he/she could go in it. The documentation indicated that abuse was substantiated and the nurse aide was terminated. Interview with Licensed Practical Nurse (LPN) #3 on 1/21/16 at 12:10 PM identified that he was the 7-3:00 PM charge nurse on 8/8/15 and when he conducted rounds at 7:00 AM he noticed Resident #1's bed was soiled with urine stains. LPN #3 stated later in the day Resident #1 reported to him that a nurse aide last night told him/her she couldn't be bothered giving the resident the urinal all night and to urinate in a brief. LPN #3 identified that the resident appeared to be upset and afraid of the nurse aide. Interview with the 3-11PM Supervisor, RN #5, on 1/20/16 at 1:10 PM identified Resident #1 reported to her NA #7 was rude, she did not have time to allow the resident to use the urinal and wanted to place a brief on the resident. RN #5 stated the resident was very upset while reporting to her and that he/she did not want NA #7 to care for him/her again. Interview with the 11-7AM RN Supervisor, RN #2, on 1/21/16 at 9:10 AM identified that throughout the shift NA #7 was speaking disrespectfully, was rude and swearing at and in front of Resident #1. RN #2 stated she did not want to confront NA #7 and she did not send NA #7 home because then she would of had to assist the other aid with incontinent care rounds and she was busy and had her own things to do. RN #2 stated she did not report the incident on 8/8/15. Interview with the former Director of Nursing (DON) on 1/21/16 at 12:20 PM identified that the 8/8/15 incident was reported to the 7-3PM Supervisor by the 7-3:00PM shift charge nurse that NA #7 was rude and swearing at Resident #1. The former DON stated that the allegation of abuse was substantiated and NA #7 was terminated. The former DON identified that RN #2 when she heard NA #7 being disrespectful and swearing at the resident should have removed the nurse aide from resident care and sent NA #7 home per the facility's policy. Review of the facility's policy and procedure for Abuse Prevention identified anyone who witnesses an incident or suspected abuse is to tell the abuser to stop immediately and report the incident to the Supervisor immediately. The policy directs the employee will be immediately removed from duty pending an investigation. Several attempts were made to contact NA #7 without success.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #10) who were reviewed for a medication error, the facility failed to transcribe a physician's order [REDACTED]. The findings include: Resident #10's [DIAGNOSES REDACTED]. The resident care plan dated 3/3/15 identified Resident #10 was at risk for [MEDICAL CONDITION] activity related to a history of [MEDICAL CONDITION] disorder. Interventions directed to maintain a safe environment, medicate as ordered and monitor for effectiveness as well as side effects and report to physician as needed. The admission Minimum (MDS) data set [DATE] identified Resident #10 had no cognitive impairments. A physician's orders [REDACTED]. The nurse's note dated 4/7/15 at 3:40 AM identified Resident #10 started yelling out at approximately 3:18 AM. Resident #10's left arm was in spam and very painful and within two (2) minutes the resident went into [MEDICAL CONDITION] activity [MEDICATION NAME] approximately five (5) minutes. Resident #10 was unresponsive, the body, arms and legs had a jerking movement, the resident's pupils were fixed and incontinent of a loose stool. The Advanced Practice Registered Nurse (APRN) was notified and directed to obtain a [MEDICATION NAME] level in the morning and to discontinue the pain medication [MEDICATION NAME] as it increases the threshold for [MEDICAL CONDITION]. The laboratory report dated 4/7/15 identified the [MEDICATION NAME] level was <0.5 (normal range 4.0-10.0 ug/mL), the physician was notified and directed to administer [MEDICATION NAME] 100 mg every twelve (12) hours. Review of the March 2015 Medication Administration Record [REDACTED]. Upon further review, the MAR failed to reflect documentation of the new order for [MEDICATION NAME] 100 mg, therefore from 3/21/15 through 4/7/15 the [MEDICATION NAME] 100 mg twice a day had not been administered for sixteen days, twenty-two (22) doses. The Reportable Event Form dated 4/7/15 at 10:00 AM identified a medication omission from 3/2215 through 4/7/15. In a written statement the Registered Nurse (RN) Supervisor, RN #6 identified that she had obtained the physician's orders [REDACTED]. Interview with the RN #6 on 1/20/16 at 12:45 PM identified that she discontinued the [MEDICATION NAME] 200 mg order and did not enter the new order [MEDICATION NAME] 100 mg into the point click care computer program.

Based on clinical record review, and interviews for the only sampled resident with a [MEDICAL CONDITION] (R#133), the facility failed to assess lung sounds and/or initiate interventions to prevent the resident from removing his/her [MEDICAL CONDITION], and/or failed to reinsert a dislodge [MEDICAL CONDITION] prior to initiating CPR. The findings include: Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's progress notes dated [DATE] noted that the resident was found with the GT out/traumatic removal. The resident was sent to the hospital for reinsertion. The hospital discharge summary dated [DATE] noted that the GT was unable to be replaced due to infection/[MEDICAL CONDITION] at the insertion site. The resident had to receive nutrition via total [MEDICATION NAME] nutrition (TPN). The care plan dated [DATE] identified a risk for complications related to [MEDICAL CONDITION]. Interventions included keep ambu bag and [MEDICAL CONDITION] in room, monitor and record lung sounds every shift, observe for respiratory difficulty and report to MD, suction as needed,[MEDICAL CONDITION] changed per MD order, keep spare trach/obturator/trach kit at bedside, and to monitor sats as ordered and prn. On [DATE], the resident was found with [MEDICAL CONDITION] removed. The resident was unable to state when or [MEDICAL CONDITION] dislodged. Sent to ED. On [DATE], the resident was reamitted to the facility. Nurse's notes dated [DATE] identified that the resident'[MEDICAL CONDITION] was again displaced with slight trauma and a moderate amount of bloodly drainage. The resident was sent to the hospital for re-insertion. On [DATE], the resident returned with a [MEDICAL CONDITION] place. Nurse's notes indicated that on [DATE] at 9:29 PM, the resident was noted with labored breathing. His/her oxygen saturation was 79 (normal over 93%). The resident was suctioned twice and had a productive cough with oxygen saturation returning to 98% on room air. No lung sounds or physician notification were documented. Nurse's notes dated [DATE] at 5:06 AM documented that resident was noted by previous shift with dyspnea. MD on call was notified. Chest xray was ordered stat. The resident's temperature was 101.4. The resident was hospitalized from ,[DATE]-[DATE] for pneumonia and bacteremia. Nurse's notes indicated that on [DATE] at 8:30 AM, resident was noted with sat at 58%, and pulse of 120. [MEDICAL CONDITION] removed and noted to be occluded with thick secretions. He/she was suctioned and [MEDICAL CONDITION] replaced with sat up to 89%. No lung sounds were documented. The APRN assessed the resident at 12:30 PM and noted rhonci in both lungs. Nurse's notes dated [DATE] at 6:07 AM noted that the resident continues to have copious amount of white sputum secretion. Contineus to have productive cough intermittently. Suctioned three times this shift with copious amounts sputum. No lung sounds were documented. Nurse's notes dated [DATE] at 1:41 PM indicated suctioning three times with large amounts of thick mucous obtained. No lung sounds were documented. Nurse's notes dated [DATE] at 4:30 PM indicated that the resident was found unresponsive and without a pulse. CPR was initiated and 911 called. [MEDICAL CONDITION] found decannulated. EMT's were unable to resuscitate and the resident was prounounced expired at 5:18 PM. Interview and clinical record review with the acting DNS on [DATE] at 1:20 PM failed to provide documentation that a care plan was developed to address the resident's behaviors and/or issues with removing the [MEDICAL CONDITION] and/or gastrostomy tube. The acting DNS was unable to find documentation of lung sounds despite the care plan directing the assessments every shift and indicated that it "would be up to the doctor to order" lung sounds. Interview with LPN#2 on [DATE] at 10:30 AM noted that a family member found the resident not breathing and called for help. LPN#2 responded and saw [MEDICAL CONDITION] was out and the resident was pale and without respirations or a heart beat. LPN#2 indicated that he/she called RN#3 for help and RN#3 began CPR while LPN#2 comforted the family member. LPN#2 indicated that at some point during the code, he/she told RN#3 that [MEDICAL CONDITION] needed to be reinserted and when RN#3 couldn't get it back in, he/she reinserted it. Interview with RN#3 on [DATE] at 10:45 AM indcated that he/she did not reinsert [MEDICAL CONDITION] initially prior to beginning CPR and then tried but LPN#2 was able to reinsert it.

Based on clinical record reviews, observations, interviews and review of facility policy for two of four residents in the survey sample reviewed for pressure ulcers (R#162 and R#168), the facility failed to provide documentation that interventions to prevent a pressure ulcer were implemented and/or failed to ensure a resident at risk for skin breakdown did not develop a pressure ulcer. The findings include: 1. Resident #162 ' s [DIAGNOSES REDACTED]. An admission MDS dated [DATE] indicated the resident had severe cognitive dysfunction, required extensive assist with bed mobility, transfers, and walking, and had no pressure ulcers. A resident care plan dated 11/11/15 identified a risk for skin breakdown as evidenced by decreased independence, mobility and incontinence. Interventions included float heels while in bed and assist the resident in repositioning frequently. A skin integrity report dated 12/22/14 indicated a new deep tissue injury (DTI) described as 4 cm x 4 cm intact, deep purple color was identified on the resident's left heel. A subsequent assessment dated [DATE] indicted the left heel wound was 1.8 cm x 1.8 cm of 50% eschar tissue and 50% necrotic tissue. A skin integrity report dated 1/16/15 indicated a new stage 2 pressure ulcer was identified on the resident's coccyx. Review of wound care specialist notes dated 12/24/14, 12/31/14, and 1/7/15 recommended to elevate legs, float heels in bed, and off-load wound. Wound care specialist notes dated 1/21/15, 1/28/15, and 2/4/15 recommended to off-load wound and reposition per facility protocol. Review of treatment records, nurse ' s notes and flow sheets dated 10/29/14 through 2/25/15 noted no documentation related to floating of the resident ' s heels in bed and/or off-loading the wound, and/or repositioning the resident frequently every shift. A review of the clinical record and interview on 2/27/15 at 1:15 PM with RN # 2 indicated off-loading R#162's heels and/or the repositioning the resident were not documented prior to the wounds being identified. Repositioning is noted occasionally in the nurse's notes after the resident developed the heel and coccyx wound, but not every shift consistently. He/she indicated it is the nurse aides and charge nurses responsibility to ensure that the interventions are implemented. RN # 2 indicated ultimately, the nurse manager would ensure the interventions as outlined in the care plan are implemented, but was unable to provide documentation of implementation of off-loading the heels and/or repositioning the resident on all 3 shifts. 2. Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident had cognitive impairment, required extensive assistance of two for bed mobility, transfers, and tilting, was at risk for developing a pressure ulcer, and presently did not have a pressure ulcer. A care plan dated 11/12/14 identified R #168 required assistance with ADL's due to a femur fracture. Interventions included knee immobilizer as ordered, and assistance of two for transfers with a gait belt and toe touch weight bearing with knee immobilizer. Physician orders [REDACTED]. The physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Nurse ' s notes dated 11/19/14 noted a new ulcer-pressure, DTI on the right outer ankle, new orders obtained, hydrogel and foam dressing. Nurse ' s notes dated 11/20/14 identified the resident with a DTI to right outer heel due to the immobilizer. The physician was notified and directed facility staff to apply the knee immobilizer for therapy and at bed time only. A wound care specialist initial evaluation dated 11/19/14 identified an unstageable DTI to the right ankle measuring 3.0 cm x 3.5 cm, no exudate with a surface area of 10.50 cm. Recommendations were to apply hydrogel daily to the wound bed. A wound care specialist evaluation dated 12/3/14 identified the right outer ankle with 100% thick, adherent devitalized necrotic tissue, measuring 3.8 cm x 1.5 cm with a surface area of 5.70 cm. with recommendation to surgically debride the area and apply silver hydrogel daily. Weekly skin integrity report dated 11/19/14 identified a DTI was noted on the right outer ankle measuring 3.0 cm x 2.5 cm no odor and/or drainage noted. Weekly skin integrity report dated 11/26/14 identified a DTI to the right outer ankle measuring 4.0 cm x 2.5 cm a minimal amount of serous drainage. Weekly skin integrity report dated 12/3/14 identified the right outer ankle as necrotic measuring 3.5 cm x 1.5 cm no odor or drainage noted. Facility wound and skin care procedures guidelines for a suspected DTI noted a DTI appears as a purple or maroon intact or blood filled blister that is firm, mushy, or boggy. Treatment recommendations direct the staff to cleanse the area and apply nutrashield protective barrier every shift and as needed. Also may apply loose, dry, protective covering if needed. Observation of the knee immobilizer with RN #2 on 2/27/15 at 10:40 AM noted the knee immobilizer had a metal bar on the medial side of the immobilizer from the hip area ending at the right outer ankle area. Additionally the immobilizer was noted, at that time, with a moderate amount of dark old drainage in the area of the right ankle. RN #2 identified that was area where the knee immobilizer metal bar was in contact with the right outer ankle. Interview and review of the clinical record with RN # 2 on 2/27/15 at 10:30 AM identified that although R #168 was to wear the right knee immobilizer at all times, the clinical record failed to reflect physician orders [REDACTED]. RN #2 indicated the charge nurse will review the hospital discharge summary and the Inter-agency referral form on admission to reconcile the medications and/or or ensure treatment orders are correct and current. The staff will verify the admission orders [REDACTED]. Although RN #2 indicated staff were documenting CMS checks he/she was unable to provide documentation that the right knee immobilizer was opened and/or released allowing staff to visualize the leg/ankle area until 11/19/14 (19 days later) when the right outer ankle was identified with a DTI.

Based on clinical record review and interviews for one (R#36) of three residents reviewed for hydration, the facility failed to monitor the resident's fluid status during an acute illness, and/or in the presence of a medication that required adequate hydration to prevent dehydration. The findings include: Resident# 36's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified R#36 required extensive assist for bed mobility and transfers. Review of laboratory data dated 4/23/14 identified R#36 with a Sodium level of 137 (normal 133-145), Creatinine of 1.4(normal 0.7-1.5) and a Blood Urea Nitrogen (BUN)of 29 (normal 10-24). Review of the resident care plan dated 5/9/14 identified the development of shingles from underneath the left breast continuing around to the back. Review of physician orders [REDACTED]. Review of the nurse's progress notes dated 5/10/14 identified R#36 refusing to hydrate. Review of the nurse's notes dated 5/11/14 at 12:00PM identified R#36 denied pain but appears listless, grimacing and writhing to indicate otherwise. The physician was contacted and [MEDICATION NAME] 5/325 was ordered every four hours for pain. On 5/13/14, poor intake was documented. Nurse's notes dated 5/14/14 identified that R#36 was noted to have right facial drooping, was unable to respond to verbal commands and lethargic. Pupils were pinpoint and R#36 had a vacant stare. The physician was notified and the resident was transferred to acute care. Review of the admission history and physical identified on physical examination, R#36 was not alert or oriented and had dry mucous membranes. R#36 was assessed to have toxic [MEDICAL CONDITION] thought to be multifactorial in the setting of dehydration, urinary tract infection and less likely disseminated [MEDICATION NAME]. Review of laboratory data dated 5/14/14 identified a Sodium level of 146 (normal 135-145), Blood Urea Nitrogen (BUN) of 50 (normal 7-28) and Creatinine 1.6 (normal 0.3 -1.2). R#36 was treated with intravenous saline. Review of laboratory data dated 5/17/14 identified that R#36's sodium level was 137, BUN 16 and Creatinine 0.8 after treatment for [REDACTED]. Review of the acute care discharge summary dated 5/19/14 identified R#36 was discharged with [MEDICAL CONDITION] secondary to dehydration and a urinary tract infection. Interview and review of the clinical record on 2/27/15 at 2:00 PM with the Director of Nursing, RN#1 and Corporate Nurse failed to provide documentation that R#36's fluid status was monitored. The staff were unable to provide policies/procedures/guidelines that identified residents for which intake and output should be initiated. According to the Physician Desk Reference (© 2015 PDR, LLC) regarding the administration of Altrax, acute [MEDICAL CONDITION] has been reported and directed that adequate hydration be maintained. Central Nervous Symptoms adverse reactions (such as agitation, hallucinations, confusion, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]) have been reported in patients with or without reduced renal function. Caution should be taken with the elderly and with renal impairment and adequate hydration is stressed. Review of facility policy directs that the implementation of an individual patent's nutrition/hydration management occurs within the care delivery process. Staff will consistency observe and monitor patients for changes and implement revisions to the plan of care as needed.

Based on review of clinical records, interviews, and review of facility policy for one sampled residents (R#35), the facility failed to appropriately monitor and report weight changes. The findings include: Resident #35's [DIAGNOSES REDACTED]. A quarterly minimum data set assessment ((MDS) dated [DATE] identified the resident with impaired cognition, and required extensive assistance for ADL's. A Care Plan dated 2/7/13 identified a potential alteration in nutritional status related to [MEDICAL CONDITION]. Interventions included weights and diet as ordered. physician's orders [REDACTED]. Review of R#35's weight record noted the following: 1/7/13 - weight 116 pounds 1/18/13 - weight 105.5 pounds (10 pound loss in 12 days) 3/9/13 - weight 107.5 pounds 3/22/13 - weight 115.3 pounds (7.5 pound weight gain) 3/27/13 - weight 113.6 pounds 4/3/13 - weight 106.7 pounds (7 pound weight loss) Weights for Resident #35 were not documented 3 days in January, four days in February, and 3 days in March. Interview and review of the clinical record with Director of Nursing Services (DNS) on 4/8/13 at 10:15 AM identified any resident identified with a three pound weight loss and/or gain within 24 hours should have a reweigh done, and the physician should be notified of the weight loss and/or gain. The clinical record failed to reflect the physician was notified when there was a loss and/or gain of two or more pounds. She could not explain why the physician orders [REDACTED]. Interview with APRN #1 on 4/8/13 at 11:15 am identified she would expect to be notified of a weight gain as outlined by the physician orders, would have changed the plan of care for Resident #35 had she been notified of a 7.8 pound weight gain in 13 days and would expect to be notified of a 7 pound weight loss.

Based on review of the clinical record, staff interview, and review of facility policy for one of three residents reviewed for pressure ulcers (Resident # 92), the facility failed to implement interventions to prevent the development and/or the deterioration of a pressure ulcer. The findings include. Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Pressure Ulcer assessment dated [DATE] identified a 1.0 centimeter (cm) x 1.0cm blood blister on the right heel. The Norton Plus Pressure Ulcer Scale dated 2/8/12 identified the resident was at high risk for pressure ulcer development. The physician's orders [REDACTED]. The admission assessment Minimum Data Set ((MDS) dated [DATE] identified impaired cognition, extensive assistance for bed mobility, two stage one pressure ulcers on the buttocks and left heel and an unstageable pressure ulcer with suspected deep tissue injury on the right heel. The Pressure Ulcer assessment dated [DATE] identified the right heel pressure ulcer was now a 4.4cm by 4.8cm unstageable area, a new stage one pressure ulcer was present on the buttock and a new 1.0cm circular stage one pressure ulcer was identified on the left heel. The Pressure Ulcer assessment dated [DATE] identified the right heel pressure ulcer was 5.0cm by 8.0cm, the left heel pressure ulcer was 3.0cm by 2.0cm and the buttock pressure ulcer was 1.8cm by 0.5cm by 0.1cm. Interview and review of the clinical record with the Director of Nurses (DNS) on 3/15/12 at 10:30am failed to reflect that from 2/8/12 through 2/20/12 (12 days) turning and repositioning was provided consistently every two hours to the resident and failed to reflect off-loading of the resident's heels was implemented per the physician's orders [REDACTED]. The DNS indicated the physician's orders [REDACTED]. The facility pressure ulcer management policy identified when a resident has a pressure ulcer at the time of admission, treatment begins promptly according to the physician's orders [REDACTED]. . . .

Based on observations, review of the clinical records, facility policy and interviews for 2 of 4 residents who utilized electric wheelchairs (Resident #50 and R #161) and/or for 1of 7 residents reviewed for falls (Resident #67), the facility failed to ensure electric wheelchairs were charged in a safe manner and/or failed to ensure interventions were implemented to prevent a fall with injury. The findings include: 1. Resident #50's [DIAGNOSES REDACTED]. The resident care plan dated 1/5/12 identified a self-care deficit with interventions that included utilizing an electric wheelchair. Observations on 3/12/12 at 7:45am, 10am and 11:30am identified the resident's electric wheelchair in the bedroom against the window seat plugged into the wall with the battery pack resting on the cushion of the window seat. Observations on 3/13/12 at 9:45am and 11:00am noted the resident's electric wheelchair in the bedroom against the window seat plugged into the outlet with the battery pack sitting on the window seat cushion. Interview with Registered Nurse (RN) #1 on 3/13/12 at 11:00am identified electric wheelchairs are to be charged in the utility room not in a resident's room. 2. Observation and interview with Resident #161 on 3/13/12 at 10:45am in identified the resident's electric wheelchair against the wall in the resident's room plugged into an electrical outlet charging. R#161 indicated the electric wheelchair is always charged in his/her room on the 3-11pm shift. Interview with Registered Nurse (RN) #1 on 3/13/12 at 11:00am identified facility policy directs electric wheelchairs to be charged in the utility room not in a resident's room. RN #1 was unable to identify why the facility policy was not implemented. 3. Resident #67's [DIAGNOSES REDACTED]. Interventions included using a bed and wheelchair sensor alarm, assisting the resident with ambulation using a walker, and to reinforce the need to call for assistance. The Minimum Data Set ((MDS) dated [DATE] identified severe cognitive impairment, difficulty focusing, disorganized thinking, trouble concentrating, resistance to care, extensive assistance for transfers, ambulation and required assistance with balance for surface to surface transfers, and walking and moving from a seated to standing position. The nurse's notes dated 6/1/11, 6/2/11, 6/4/11 and 6/6/11 identified Resident #67 spontaneously standing and ambulating from the wheelchair without calling for assistance. The notes identified the resident had unsteady balance, was confused, and had poor safety awareness. The nurse's note/change of condition documentation dated 6/29/11 at 10:28am identified Resident #67 was found in the television room on his/her knees with the sensor alarm sounding. An assessment at that time identified no injury; however, the nurse's note dated 6/29/11 at 10:00pm identified an ecchymotic area on the forehead and bridge of the nose with a lump present. The nurse's note dated 6/30/12 at 7:30pm noted bruising to the nose with minimal swelling. The physician was notified and directed to obtain an x-ray. The x-ray report dated 6/30/11 identified a nondisplaced nasal bone fracture. The Reportable Event dated 6/29/11 at 10:00am identified an unwittnessed fall in the television room. The investigation identified a statement from the charge nurse that identified the resident frequently attempted to stand and/or get out of the wheelchair without assistance from staff. Review of the clinical record and staff interviews with the Director of Nurses (DNS), Assistant Director of Nurses (ADNS) and the Unit Manager on 3/15/12 at 11:45am identified that although the resident was at risk for falls and the staff were aware the resident made several attempts to stand on his/her own, interventions were not implemented in the care plan to address the resident's behavior to prevent an accident.

Based on review of the clinical record, facility documentation and interview for one of four sampled residents reviewed for accidents (Resident #226), the facility failed to prevent an accident with injury. The findings include: Resident #226's [DIAGNOSES REDACTED]. The fall assessment dated [DATE] identified a fall risk with assistance required for bed mobility, transfer or ambulation. The annual Minimum Data Set assessment dated [DATE] identified short and long term memory problems, severe impairment in decision making, total dependence for activities of daily living, one person assistance for bed mobility and no recent falls. The Resident Functional Performance Record from 6/1/10 through 6/8/10 identified dependence bed mobility with the support of two or more people. The Nursing Assistant Care Card, last updated 3/24/10, indicated the resident required extensive assistance for bed mobility with the support of two and total assistance for bathing. The Reportable Event dated 6/8/10 identified Nurse Aide (NA) #4 was providing a bed bath to the resident and the resident slipped off the bed onto the floor. The physician was notified and directed to obtain an X-ray of the left hip. The X-ray report dated 6/8/10 identified an intertrochanteric fracture of the left hip. NA #4 was provided education to review the care card prior to caring for the resident, not to provide care for a resident until the resident ' s care plan is understood and to ask for staff assistance if the resident requires assistance of two for any activity of daily living. Interview with NA #4 on 2/9/11 at 2:00 PM indicated the resident was in the sitting position in bed and while giving the resident a bath, the resident's legs started sliding off the right side of the mattress and she was unable to prevent the resident from falling to the floor. NA #4 indicated prior to 6/8/10 she had not taken care of the resident and did not know two staff were required for care.

Based on review of the clinical record, facility documentation and interviews for one of two sampled residents reviewed for medication errors (Residents #124), the facility failed to ensure the resident was free from significant medication errors. The findings include: 1a. Resident #124's [DIAGNOSES REDACTED]. The Oncology Consultation Report dated 8/25/10 recommended to administer GCSF ([MEDICATION NAME]) 300 mcg on 8/26/10, 8/27/10, 8/28/10, 8/29/10 and 8/30/10 and noted the resident's white blood cell count was 4.2 LL. The physician's orders [REDACTED]. The Reportable Event dated 8/29/10 identified Charge Nurse #1 inadvertently interpreted the abbreviation GCSF to mean [MEDICATION NAME] and documented the incorrect medication on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Reportable Event noted Charge Nurse #1 misinterpreted GCSF as an abbreviation for [MEDICATION NAME] and failed to clarify the order with the physician. After notification on 8/29/10, the physician directed to discontinue [MEDICATION NAME] and administer [MEDICATION NAME], (GCSF), on 8/30/10 and 8/31/10. The August 2010 MAR indicated [REDACTED]. The nurse's note dated 8/30/10 identified the resident developed a temperature of 99.9 Fahrenheit on 8/30/10 and the white blood cell count was 0.1 LL. Resident #124 was admitted to the hospital with [REDACTED]. The DNS indicated Charge Nurse #1 failed to clarify the physician's orders [REDACTED]. The DNS indicated GCSF is not the abbreviation for [MEDICATION NAME] and facility policy that directs the licensed nurse to contact the ordering physician to clarify an order any time the order is in question for any reason was not followed. Interview with Oncology Registered Nurse (RN) #1 on 2/24/11 at 11:20 AM indicated [MEDICATION NAME] was ordered because the resident was receiving [MEDICAL CONDITION] and it was important to maintain blood count levels during therapy. RN #1 further stated the omitted [MEDICATION NAME] doses put the resident at risk for [DIAGNOSES REDACTED] and infectious processes. b. Resident #124 was readmitted to the facility on [DATE]. The physician discharge orders directed to administer [MEDICATION NAME] 300 mcg for two additional days. The September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Reportable Event dated 9/7/10 indicated the 9/5/10 dose was misread and was not administered and on 9/6/10 [MEDICATION NAME] was omitted because the charge nurse thought the medication was not delivered by the pharmacy. The Physician directed to obtain a complete blood count (CBC) and administer a dose of [MEDICATION NAME] 300 mcg immediately. The CBC dated 9/7/10 identified a white blood count of 6.9 and the physician discontinued the second dose of [MEDICATION NAME]. Interview with the Director of Nurses (DNS) on 2/11/11 at 11:00 AM indicated although the [MEDICATION NAME] was ordered and delivered by the pharmacy appropriately the medication were not administered as ordered.